Aetna Romosozumab-aqqg (Evenity) Coverage Policy Update — CPB 0954 (2026)

Aetna, a CVS Health company, has modified Clinical Policy Bulletin CPB 0954 governing coverage of romosozumab-aqqg (Evenity) for postmenopausal osteoporosis, effective March 13, 2026. This update refines the medical necessity criteria for both initial approval and continuation of therapy — and because Evenity requires precertification across all applicable Aetna commercial plan designs, any gap in documentation will translate directly into denials.

What Changed: Aetna CPB 0954 Evenity Medical Necessity Criteria

The March 2026 modification to CPB 0954 clarifies and structures the approval pathway for romosozumab-aqqg into two distinct tracks, both applicable to postmenopausal osteoporosis only. Aetna explicitly designates all other indications as experimental, investigational, or unproven — a designation that carries real denial and appeals risk.

For billing and revenue cycle teams, the critical point is this: Evenity approval now requires that members fit one of two clearly defined eligibility gates, and documentation must map precisely to those gates at the time of precertification.

Aetna Evenity Initial Approval Criteria: Two Pathways

Pathway 1 — History of Fragility Fracture

The member must have a documented history of a fragility fracture — defined as a low-trauma fracture resulting from a force equivalent to a fall from standing height. This is the most straightforward approval route. Your clinical documentation should capture the fracture mechanism explicitly; "low-trauma" language in chart notes will carry weight during medical necessity review.

Pathway 2 — T-Score and FRAX-Based Criteria (with Subsets)

Members who lack a fragility fracture history can still qualify, but the documentation burden is higher. Aetna requires a pre-treatment T-score of ≤ -2.5 or a diagnosis of osteopenia (T-score between -1 and -2.5) paired with a high FRAX probability score per Aetna's defined thresholds (see the Appendix in CPB 0954 directly). From there, the member must also meet at least one of three additional sub-criteria:

1. Very high fracture risk indicators — advanced age, frailty, glucocorticoid use, T-score ≤ -3, or increased fall risk
2. Inadequate response or intolerance to prior injectable osteoporosis therapy — specifically zoledronic acid (Reclast, HCPCS J3489), teriparatide (Forteo, HCPCS J3110), a denosumab product including biosimilars (Prolia, HCPCS J0897; stoboclo/osenvelt, Q5157; denosumab-bnht/bomyntra/conexxence, Q5158; denosumab-dssb/ospomyv/xbryk, Q5159), or abaloparatide (Tymlos)
3. Inadequate response or intolerance to oral bisphosphonate therapy — no specific HCPCS code required, but documentation of the trial and failure is essential

The policy's explicit enumeration of prior therapies—including the newer denosumab biosimilars—signals that Aetna expects detailed step therapy documentation. Vague references to "prior osteoporosis treatment" will not be sufficient.

Aetna Evenity Continuation of Therapy Requirements

Aetna will consider continuation of Evenity medically necessary when the member—including newly enrolled members switching from another plan—meets all initial selection criteria and has received fewer than 12 monthly doses. This 12-dose cap aligns with the FDA-approved treatment course and means continuation authorizations are effectively time-limited by design. Once a member completes 12 monthly doses, the policy does not provide for additional Evenity coverage—sequential antiresorptive therapy would then need to be addressed under a different policy.

For new members mid-course, ensure you document their dose count and the qualifying criteria from their previous plan at the time of precertification.

Prior Authorization Requirements for Evenity Under Aetna

Precertification is mandatory for all Aetna participating providers and members in applicable commercial plan designs. There are no exceptions noted in CPB 0954. Use the following contacts:

• Phone: (866) 752-7021
• Fax: (888) 267-3277
• SMN Precertification Forms: Available via Aetna's Specialty Pharmacy Precertification portal

This policy covers commercial medical plans only. Medicare criteria are handled separately through Aetna's Medicare Part B Step Therapy requirements — do not apply CPB 0954 criteria to Medicare Advantage patients.

Affected Codes

Covered Code — Evenity Injection

Step Therapy / Prior Therapy Reference Codes

These codes represent the prior injectable therapies Aetna expects to see documented as part of the step therapy criteria under Pathway 2:

Relevant ICD-10-CM Diagnosis Codes

Note that M81.8 carries a specific exclusion notation in the policy: it is not covered for glucocorticoid-induced osteoporosis. Flag any claims where that is the primary diagnosis before submitting.

What Your Billing Team Should Do