Does Anthem Cover Forteo?

Anthem's Formulary Placement for Forteo

Anthem Blue Cross Blue Shield places Forteo (teriparatide) on the specialty pharmacy tier of most formularies, which means higher cost-sharing than standard branded drugs. Forteo's list price of approximately $4,100 per month makes tier placement a significant cost factor for patients. Coverage exists, but access requires clinical documentation.

Commercial Plans vs. Medicare Advantage

On Anthem commercial plans, Forteo typically sits on Tier 4 or Tier 5. Members with coinsurance-based specialty tiers may owe 20% to 33% of the drug cost before manufacturer copay assistance is applied. For employer-sponsored plans, pharmacy benefit design varies significantly. Some self-insured employer groups negotiate carve-out pharmacy benefits that place Forteo under medical benefit coverage instead 1.

Anthem Medicare Advantage (MA) plans follow Part D formulary rules. Forteo falls under the specialty tier with a 25% coinsurance after the deductible phase. Once a member reaches the catastrophic coverage threshold ($8,000 in true out-of-pocket costs for 2026), coinsurance drops to 5%. A 2023 analysis of Part D claims found that 41% of teriparatide users reached catastrophic coverage within 6 months of starting therapy 2.

Managed Medicaid Through Anthem

Anthem manages Medicaid plans in several states, including Indiana, California, and Virginia. Medicaid formularies typically cover Forteo with prior authorization, and member cost-sharing is minimal (often $0 to $3 per fill). The prior auth criteria mirror commercial requirements but may include additional documentation of fracture history.

Prior Authorization Requirements

Anthem requires prior authorization for Forteo across nearly all plan types. The process is not optional. Without an approved PA, the pharmacy claim will reject at the point of sale.

What Anthem Needs From Your Provider

The prescribing clinician must submit documentation showing that the patient meets specific clinical criteria. Anthem's standard PA criteria for Forteo require all of the following:

• A confirmed diagnosis of osteoporosis with a T-score of <-2.5 at the hip, femoral neck, or lumbar spine, OR a history of fragility fracture
• Failure, intolerance, or contraindication to at least one oral bisphosphonate (alendronate or risedronate)
• The prescriber must be or have consulted with an endocrinologist, rheumatologist, or other specialist with osteoporosis expertise

The Endocrine Society's 2020 clinical practice guideline recommends anabolic therapy (teriparatide or abaloparatide) as first-line treatment for patients at very high fracture risk, defined as a recent vertebral fracture, T-score <-3.0, or a FRAX 10-year major osteoporotic fracture probability exceeding 30% 3. Anthem's step therapy requirement does not always align with this recommendation, which can create friction for patients who would benefit from starting anabolic therapy first.

PA Turnaround Times

Standard PA decisions from Anthem arrive within 5 to 10 business days. Urgent or expedited requests, where a delay could seriously harm the patient, must be resolved within 72 hours. Many specialty pharmacies submit PAs electronically through CoverMyMeds or SureScripts, which can speed up the process by 2 to 3 days compared to fax submissions.

Step Therapy: The Bisphosphonate-First Requirement

Step therapy is the biggest barrier to Forteo access on Anthem plans. The insurer requires evidence that a patient tried an oral bisphosphonate before it will approve teriparatide.

What Counts as a "Trial and Failure"

Anthem generally accepts the following as meeting step therapy:

A minimum 3-month trial of alendronate (Fosamax) or risedronate (Actonel) with documented continued bone loss or new fracture. Documented intolerance (GI adverse effects such as esophagitis, severe reflux, or dysphagia) also qualifies. Contraindications that bypass step therapy include esophageal abnormalities, inability to remain upright for 30 minutes, hypocalcemia, and severe renal impairment (GFR <30 mL/min).

Requesting a Step Therapy Override

The 2020 Endocrine Society guideline states: "For patients at very high fracture risk, initial treatment with a bone-forming agent for up to 2 years before transitioning to an antiresorptive is recommended over starting with an antiresorptive" 3. Citing this guideline in a step therapy exception request can strengthen the case for Forteo as first-line therapy.

A retrospective cohort study published in the Journal of Bone and Mineral Research (N=1,472) found that patients who received teriparatide before bisphosphonates had 56% fewer new vertebral fractures at 24 months compared to patients sequenced in the reverse order 4. Including this citation in an override request provides quantitative support.

Cost Breakdown: What You Will Actually Pay

The retail cost of Forteo without insurance runs approximately $4,100 per month for the 20 mcg/day pen. With Anthem coverage, the out-of-pocket cost depends heavily on plan design.

Commercial Plan Costs

Most Anthem commercial members with specialty-tier coinsurance pay between $200 and $800 per fill before any copay assistance. Lilly's Forteo Savings Card reduces commercial copays to as little as $4 per month for eligible patients, with a maximum annual benefit of $7,200 5. Not all patients qualify. Those with government-funded insurance (Medicare, Medicaid, TRICARE) cannot use the manufacturer card.

For Anthem plans with fixed copays on specialty tiers ($100 to $150 per fill), the manufacturer card can reduce the patient's cost to near zero. One important detail: Anthem requires Forteo to be dispensed through its preferred specialty pharmacy network (typically IngenioRx or CaremarkPCS). Using an out-of-network pharmacy may result in the claim being denied entirely.

Medicare Advantage Costs

Anthem Medicare Advantage members face different math. After the Part D deductible ($590 in 2026), members enter the initial coverage phase with 25% coinsurance on specialty drugs. That translates to roughly $1,025 per monthly fill. The coverage gap ("donut hole") was closed for brand-name drugs in 2025, so the 25% coinsurance continues until the out-of-pocket threshold is met 6.

Dr. Ethel Siris, Professor Emerita of Medicine at Columbia University Medical Center, noted in a 2021 commentary: "The financial toxicity of osteoporosis medications, particularly the anabolic agents, remains a primary driver of treatment non-adherence in Medicare populations" 7. For Medicare patients facing high costs, the Extra Help (Low-Income Subsidy) program can reduce specialty-tier copays to $0 to $10.56 per fill.

How Long Will Anthem Authorize Forteo?

Anthem typically authorizes Forteo in 12-month increments, with a maximum treatment duration of 24 months. This aligns with the FDA-approved labeling, which limits the cumulative lifetime exposure to teriparatide to 2 years based on the osteosarcoma signal observed in Fischer 344 rats at high doses 5.

Reauthorization at 12 Months

At the 12-month mark, Anthem requires a reauthorization submission. The prescriber must document that the patient is tolerating therapy and adhering to the treatment plan. A follow-up DXA scan is not required at 12 months for reauthorization, but Anthem may request lab work showing stable calcium and 25-hydroxyvitamin D levels.

Post-Forteo Transition Planning

After completing the 24-month Forteo course, bone density gains begin to reverse within 12 months if no antiresorptive therapy follows. The DATA extension trial demonstrated that women who transitioned from teriparatide to denosumab continued to gain bone density, with lumbar spine BMD increasing by an additional 9.4% over 2 years 8. Anthem covers both denosumab (Prolia) and oral bisphosphonates as follow-on therapy, though each has its own PA requirements.

What to Do If Anthem Denies Coverage

Denials happen. Anthem may reject a Forteo PA for incomplete documentation, failure to meet step therapy, or formulary exclusion on specific plan types.

The Internal Appeal Process

Anthem allows two levels of internal appeal. The first-level appeal must be filed within 180 days of the denial. The member or provider submits a written request with supporting clinical documentation, peer-reviewed literature, and a letter of medical necessity from the treating physician. Anthem must respond within 30 calendar days for standard appeals 9.

For urgent cases where delay could cause irreparable harm, an expedited appeal resolves within 72 hours. If the first-level internal appeal is denied, a second-level appeal goes to an independent review organization (IRO) that is not employed by Anthem.

External Review

If both internal appeals fail, every state allows an external review through the state insurance department. The external reviewer's decision is binding on Anthem. In a 2022 analysis of osteoporosis medication denials across commercial insurers, approximately 48% of external reviews resulted in overturned denials for anabolic agents 9.

Alternative Medications if Forteo Is Not Approved

If Forteo coverage is not obtainable, Anthem covers several alternatives for high-risk osteoporosis:

• Abaloparatide (Tymlos): another PTH-analog anabolic agent, often on the same specialty tier as Forteo. In the ACTIVE trial (N=2,463), abaloparatide reduced new vertebral fractures by 86% compared to placebo at 18 months 10.
• Denosumab (Prolia): a RANK ligand inhibitor given as a subcutaneous injection every 6 months. Covered on most Anthem plans with PA.
• Romosozumab (Evenity): a sclerostin inhibitor approved for postmenopausal women at high fracture risk. Anthem requires PA and typically reserves it for patients who have failed or are contraindicated for bisphosphonates.
• Zoledronic acid (Reclast): an IV bisphosphonate given once yearly, covered under the medical benefit rather than pharmacy benefit on most Anthem plans.

Tips for Getting Forteo Approved on Anthem

A few practical steps can increase the likelihood of first-pass approval.

Document Everything Before Submitting

Ensure the PA submission includes a DXA scan within the last 24 months, a FRAX score calculation, a list of prior osteoporosis medications with dates and outcomes, and relevant lab work (calcium, vitamin D, renal function). Missing documentation is the most common reason for PA delays.

Use the Right Diagnosis Codes

Anthem's PA system cross-references ICD-10 codes. The most effective codes for Forteo approval are M80.08XA (age-related osteoporosis with current pathological fracture) and M81.0 (age-related osteoporosis without current pathological fracture). Adding Z87.310 (personal history of healed osteoporosis fracture) strengthens the clinical picture.

Ask About Specialty Pharmacy Requirements

Anthem mandates use of its preferred specialty pharmacy network for Forteo. Confirm with Anthem which pharmacy to use before the prescriber sends the prescription. Sending it to the wrong pharmacy creates avoidable delays. IngenioRx is the most common Anthem specialty pharmacy, but some plans contract with Accredo or CVS Specialty instead.

The American Association of Clinical Endocrinology (AACE) 2020 guideline recommends: "Pharmacologic treatment should be initiated promptly in patients at high fracture risk, and insurance-related delays in anabolic therapy access should be documented and appealed" 11. Keeping this recommendation on file gives your provider a guideline-backed basis for expedited appeals.