`Q5167` Inj, denosumab-qbde, 1 mg

Injection, denosumab-qbde (enoby/xtrenbo), biosimilar, 1 mg

Medicare coverage: Carrier judgment
Status: active (October 2026 file)

Medicare pricing for Q5167

Medicare Part B drug payment limit (ASP, October 2026)

Q5167 payment limit: $7.681 per 1 MG, effective October 1, 2026 through December 31, 2026, based on 2Q26 ASP data. Coinsurance 20%. Note: Added October 2026; 8% of reference add-on applied.

NDCs that bill under Q5167 (CMS ASP NDC-HCPCS crosswalk, October 2026)

00143-9165-01 Enoby, Hikma Pharmaceuticals USA Inc.: 60 billing units per package (1 SYRINGE in 1 CARTON / 1 mL in 1 SYRINGE)
00143-9166-01 Xtrenbo, Hikma Pharmaceuticals USA Inc.: 120 billing units per package (1 VIAL, SINGLE-DOSE in 1 CARTON / 1.7 mL in 1 VIAL, SINGLE-DOSE)

Physician Fee Schedule (CY 2026, RVU26D)

Status E: excluded from the PFS by regulation.

Payer policies and prior authorization for Q5167

40 of 40 payer prior-auth lists that name Q5167 require prior authorization or set conditions: Aetna, Blue Cross Blue Shield of Arizona (AZ Blue), Blue Cross and Blue Shield of Texas, Blue Shield of California Promise Health Plan, CarePlus Health Plans, Cigna, HealthSpring, Humana, Molina Healthcare of Illinois, Passport by Molina Healthcare (Kentucky), UnitedHealthcare, UnitedHealthcare Community Plan.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Cross Blue Shield of Arizona (AZ Blue)	AZ Blue-administered Medicare Advantage (M2K)	AZ	prior auth required		Sep 1, 2026	AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required	site of care: site-of-service review	Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Standard PA code list (most commercial plans)	AZ	prior auth required	site of care: site-of-service review	Sep 1, 2026	AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	State of Arizona employee group (SYD, S3Z)	AZ	prior auth required	site of care: site-of-service review	Sep 1, 2026	State of Arizona Group Prior Authorization Requirements Code List (09/01/2026)
Blue Cross Blue Shield of Arizona (AZ Blue)	Teamsters group (TYW)	AZ	prior auth required		Sep 1, 2026	Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026)
Blue Shield of California Promise Health Plan	Promise Health Plan Medi-Cal	CA	prior auth required		Sep 1, 2026	Medi-Cal Prior Authorization List
Aetna	Medicare Advantage	All	prior auth required		Apr 1, 2026	Participating provider precertification list for Aetna®
Aetna	Commercial	All	prior auth required	site of care: drug and site of care	Apr 1, 2026	Participating provider precertification list for Aetna®
Aetna	Commercial	All	prior auth required		Apr 1, 2026	Participating provider precertification list for Aetna®
Aetna	Medicare Advantage	All	prior auth required	Step therapy applies	Aug 25, 2026	Aetna Medicare Part B drug list (partbname.xml)
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jul 1, 2026	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required	May be delegated to eviCore for some clients	Jul 1, 2026	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Jul 1, 2026	Master Precertification List (For Health Care Providers)
Blue Cross and Blue Shield of Texas	Texas PA exemption (gold card), outpatient, fully insured	TX	prior auth required	Gold-card exemption available	Jul 1, 2026	BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range)
HealthSpring	Medicare Advantage	All	prior auth required		Aug 1, 2026	2026 Q4 Prior Authorization List
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required	Step therapy; NDC required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi
Humana	Humana D-SNP (FL)	FL	prior auth required	Step therapy; NDC required	Jul 1, 2026	H1036-280 Humana Fully Integrated Florida prior authorization and notification list
Humana	Humana D-SNP (IL)	IL	prior auth required	Step therapy; NDC required	Jan 1, 2027	Humana Dual Fully Integrated Illinois prior authorization and notification list
Humana	Humana D-SNP (IN)	IN	prior auth required	Step therapy; NDC required	Jan 1, 2027	Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes:
Humana	Humana D-SNP (MI)	MI	prior auth required	Step therapy; NDC required	Oct 14, 2026	Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL)
Humana	Humana D-SNP (SC)	SC	prior auth required	Step therapy; NDC required	Jul 1, 2026	Humana Dual Integrated South Carolina prior authorization and notification list
Humana	Humana D-SNP (VA)	VA	prior auth required	Step therapy; NDC required	Jul 1, 2026	Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia)
Humana	Humana Healthy Horizons	KY	prior auth required	NDC required	Oct 7, 2026	Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
Humana	Humana Healthy Horizons	KY	prior auth required	NDC required	Oct 7, 2026	Humana Healthy Horizons in Kentucky Prior Authorization and Notification List
Humana	Humana Healthy Horizons	OH	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Ohio prior authorization and notification List
Humana	Humana Healthy Horizons	OH	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Ohio prior authorization and notification List
Humana	Humana Healthy Horizons	OK	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List
Humana	Humana Healthy Horizons	OK	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Oklahoma Prior Authorization and Notification List
Humana	Humana Healthy Horizons	SC	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in South Carolina prior authorization and notification list
Humana	Humana Healthy Horizons	SC	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in South Carolina prior authorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required	NDC required	Oct 14, 2026	Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list
Humana	Humana MA and D-SNP	All	prior auth required	Step therapy; NDC required	Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes:
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Jul 1, 2026	Molina Healthcare of Illinois Codification Grid Q3 2026
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required	cancer dx via Evolent	Jul 1, 2026	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
UnitedHealthcare	Preferred Care Network and Preferred Care Partners of Florida	FL	prior auth required		Oct 1, 2026	Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Individual Exchange plans	All	prior auth required		Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Individual Exchange plans Effective October 1, 2026
UnitedHealthcare	UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP)	All	prior auth required	Excluded plans: for therapeutic radiopharmaceuticals: UHC Nursing Home Plan and UHC Care Advantage Plan (I-SNP)	Oct 1, 2026	UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026
UnitedHealthcare Community Plan	Massachusetts Senior Care Options (SCO) and OneCare	MA	prior auth required		Oct 1, 2026	Prior authorization requirements for Massachusetts MA SCO OneCare Effective October 1, 2026
UnitedHealthcare Community Plan	UnitedHealthcare Community Plan of Hawaii (QUEST Integration)	HI	prior auth under conditions	site of care: outpatient	Oct 1, 2026	Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026

Payer coverage policies that name Q5167

Q5167 appears in 16 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, UnitedHealthcare, Wellmark Blue Cross Blue Shield.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Denosumab (0804)	covered if criteria are met	Aug 21, 2026	payer document
Aetna	Romosozumab-aqqg (Evenity) (0954)	listed, no stance	Oct 1, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Biosimilar Medications (L.5.01.593)	listed, no stance		payer document
Blue Cross & Blue Shield of Mississippi	Biosimilar Medications (S.5.01.593)	listed, no stance		payer document
Centene	Denosumab (Prolia, Xgeva), Denosumab-bbdz (Jubbonti, Wyost), Denosumab-dssb (Ospomyv, Xbryk), Denosumab-bmwo (Stoboclo, Osenvelt), Denosumab-bnht (Bomyntra, Conexxence), (CP.PHAR.58)	covered if criteria are met	Aug 1, 2026	payer document
Centene	Denosumab (Prolia, Xgeva), Denosumab-bbdz (Jubbonti, Wyost), Denosumab-dssb (Ospomyv, Xbryk), Denosumab-bmwo (Stoboclo, Osenvelt), Denosumab-bnht (Bomyntra, Conexxence), (CP.PCH.63)	covered if criteria are met	Aug 1, 2026	payer document
Cigna	Bone Modifiers – Denosumab Products (Prolia) Prior Authorization (IP0331)	covered if criteria are met	Sep 1, 2026	payer document
Cigna	Bone Modifiers – Denosumab Products (Xgeva) Prior Authorization (IP0332)	covered if criteria are met	Sep 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Denosumab and Biosimilars for Non-Oncologic Indications (RX501.140) HCPCS Codes C9399, J0897, J3490, J3590, J9999, Q5136, Q5157, Q5158, Q5159,	listed, no stance	Jan 1, 2027	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Oncology and Supportive Care Medications (RX502.061) tqjs \| Hybreza™	listed, no stance	Jan 1, 2027	payer document
Premera Blue Cross	Denosumab Products (5.01.658) Page \| 8 of 17 \| ∞	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Denosumab (CS2026D0068Y)	listed, no stance	Sep 1, 2026	payer document
UnitedHealthcare	Denosumab (2026D0068T)	listed, no stance	Jul 1, 2026	payer document
UnitedHealthcare	Maximum Dosage and Frequency (CS2026D0034AV)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Medicare Part B Step Therapy Programs (IAP.001.30) Non-Preferred	listed, no stance	Jul 1, 2026	payer document
Wellmark Blue Cross Blue Shield	Denosumab (05.06.03)	listed, no stance	Jun 1, 2026	payer document

Recent prior-auth changes

Oct 14, 2026: PA removed, Humana
Oct 1, 2026: PA added, UnitedHealthcare
Oct 1, 2026: PA added, UnitedHealthcare Community Plan
Sep 1, 2026: PA added, Blue Shield of California Promise Health Plan
Aug 1, 2026: PA removed, Blue Shield of California Promise Health Plan
Aug 1, 2026: PA added, HealthSpring
Jul 1, 2026: PA added, Humana
Jul 1, 2026: PA added, Passport by Molina Healthcare (Kentucky)
Jul 1, 2026: PA added, UnitedHealthcare
Jul 1, 2026: PA added, UnitedHealthcare

Medicaid fee-for-service

Prior authorization required or conditional in WA.

AZ: $3.91 (asc), effective Oct 1, 2026
IL: $382.40 (practitioner), effective Jul 1, 2026
KS: $4.12 (asc, facility), effective Jul 1, 2026
MS: $3.30 (comprehensive, facility), effective Jul 1, 2026
NE: $5.69 (injectables), effective Jul 1, 2026
OK: $4.00 (physician, non-facility), effective Jul 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Jul 1, 2026
WA: $4.00 (professional_administered_drugs), effective Jul 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

Q5167 Inj, denosumab-qbde, 1 mg