Does Christiana Care Health System Cover Forteo?

What Christiana Care Health System Actually Is, and Why That Matters for Coverage

ChristianaCare (formerly Christiana Care Health System) is a Delaware-based nonprofit health system operating hospitals, outpatient clinics, and a medical group. It is not a health insurance company in the traditional sense. Coverage of Forteo for any patient seen at ChristianaCare depends entirely on the health insurance plan that patient carries, whether that is a commercial plan, Medicare Part D, Delaware Medicaid (DHSS), or the employee health benefit plan ChristianaCare offers its own workforce.

ChristianaCare as a Health System vs. A Payer

When patients ask whether "Christiana Care covers Forteo," they are usually asking one of three distinct questions:

1. Does my insurance plan, which I access through a ChristianaCare-affiliated employer or exchange, cover Forteo?
2. Does ChristianaCare's internal employee health plan cover Forteo for its staff?
3. Will a ChristianaCare endocrinologist or rheumatologist prescribe Forteo and manage my insurer's prior authorization process?

The answer to question three is yes, ChristianaCare's Metabolic Bone Disease and Rheumatology programs routinely prescribe teriparatide and submit prior authorizations on behalf of patients [see ChristianaCare's specialty pharmacy services at christiana care.org]. The answers to questions one and two depend on plan-specific formularies that change annually.

ChristianaCare Employee Health Benefits

ChristianaCare employs roughly 14,000 people in the mid-Atlantic region and self-funds a large portion of its employee health benefit program. Self-insured employer plans are governed by ERISA rather than state insurance mandates, which means Delaware's Medicaid formulary rules do not automatically apply. Specialty drugs such as teriparatide are typically covered at the specialty tier of self-insured plans but require prior authorization confirming a diagnosis of osteoporosis with a T-score at or below -2.5, or a prior low-trauma fracture.

If you are a ChristianaCare employee, your plan documents and the Summary Plan Description (SPD) are the authoritative source. Contact the HR benefits line or the specialty pharmacy partner listed on your insurance card to confirm Forteo's current tier and any step-therapy requirement.

What Is Forteo (Teriparatide) and Who Needs It?

Forteo is the brand-name version of teriparatide, a recombinant form of the first 34 amino acids of human parathyroid hormone. Unlike antiresorptive agents such as alendronate or denosumab, teriparatide works by stimulating new bone formation, making it one of the few anabolic options available for osteoporosis.

FDA Approval and Indications

The FDA approved Forteo in 2002 for postmenopausal women with osteoporosis at high fracture risk, men with primary or hypogonadal osteoporosis, and men and women with glucocorticoid-induced osteoporosis [1]. The approved daily dose is 20 mcg subcutaneously, and the lifetime cap is 24 months because of a historical black-box warning related to osteosarcoma observed in rodent studies at supratherapeutic doses, a risk that has not materialized in the human pharmacovigilance database accumulated since 2002 [2].

Clinical Efficacy Data

The Fracture Prevention Trial enrolled 1,637 postmenopausal women with prior vertebral fractures. Teriparatide 20 mcg reduced new vertebral fracture risk by 65% (relative risk 0.35, 95% CI 0.22 to 0.55, P<0.001) and nonvertebral fragility fractures by 53% compared with placebo over a median of 21 months [3]. Bone mineral density (BMD) at the lumbar spine increased by 9.7% versus a 2.4% increase in the placebo group.

The American Association of Clinical Endocrinology (AACE) 2020 Clinical Practice Guidelines designate teriparatide as a first-line anabolic agent for patients with very high fracture risk, defined as a prior vertebral or hip fracture, very low T-score (below -3.0), or fracture on antiresorptive therapy [4].

When Insurers Typically Approve Teriparatide

Most payers, including Medicare Part D plans accessible at ChristianaCare-affiliated pharmacies, require at least one of the following before approving Forteo:

• DXA-confirmed T-score at or below -2.5 at the lumbar spine or hip
• A history of low-trauma vertebral, hip, or wrist fracture
• Failure of, intolerance to, or contraindication to at least one bisphosphonate (step-therapy requirement)
• Glucocorticoid use at a prednisone-equivalent dose of 5 mg/day or more for 3 or more months

The step-therapy requirement is the most common denial trigger. Patients who have never tried alendronate or risedronate are frequently required to do so first, even when a clinician believes teriparatide is the superior initial choice given fracture severity.

How Insurance Coverage Works for Forteo at ChristianaCare Facilities

Commercial Insurance Plans

Blue Cross Blue Shield of Delaware, Highmark, Aetna, Cigna, and UnitedHealthcare all have plans sold in the Wilmington and Newark, Delaware, market where ChristianaCare operates. Each plan places teriparatide on a specialty tier, typically tier 4 or tier 5, with cost-sharing ranging from $150 to $700 per fill depending on deductible status.

Prior authorization (PA) documents must be submitted by the prescribing provider. ChristianaCare's specialty pharmacy and outpatient pharmacies can coordinate PA submission, but the prescriber's office must supply clinical documentation including the DXA report, fracture history, and any prior osteoporosis medication trials.

Approval timelines vary: standard PA decisions typically take 3 to 5 business days; urgent PA requests may be processed in 24 to 72 hours.

Medicare Part D Coverage

Medicare Part D does not have a single national formulary. ChristianaCare patients who are Medicare beneficiaries may be enrolled in any of the Part D plans available in Delaware, each with its own formulary. The CMS National Drug Code for teriparatide (brand and generic) is covered by the majority of Part D plans, but coverage is always at the specialty tier with a PA requirement [5].

The Medicare coverage gap (the former "donut hole") was eliminated for most drugs by 2024 under the Inflation Reduction Act, which caps Medicare Part D out-of-pocket drug spending at $2,000 per year starting in 2025 [6]. For patients previously rationing injectable teriparatide because of catastrophic-phase costs, this cap is a meaningful shift.

Delaware Medicaid (DHSS / Diamond State Health Plan)

Delaware Medicaid covers teriparatide for eligible beneficiaries, subject to PA. The Delaware Division of Medicaid and Medical Assistance (DMMA) Preferred Drug List (PDL) requires prescribers to document a T-score at or below -2.5 and either a prior fragility fracture or failure of bisphosphonate therapy. Managed care organizations contracted with DHSS, including Highmark Health Options and AmeriHealth Caritas Delaware, may apply additional PA criteria.

Prior Authorization: Step-by-Step for ChristianaCare Patients

Obtaining a PA for Forteo at a ChristianaCare prescribing site follows a predictable sequence.

Step 1: Clinical Documentation Assembly

The prescribing physician (endocrinologist, rheumatologist, or primary care) must collect:

• The most recent DXA report with T-scores at the lumbar spine, total hip, and femoral neck
• Fracture history (imaging reports, operative notes, or radiology reads)
• A list of prior osteoporosis medications with dates and reason for discontinuation
• Current glucocorticoid prescriptions if applicable
• FRAX score (the WHO fracture risk assessment tool) showing 10-year major osteoporotic fracture probability of 20% or more, or hip fracture probability of 3% or more [7]

Step 2: PA Submission

The prescriber's office submits the PA electronically through the insurer's portal or via fax. ChristianaCare's integrated health system means that electronic health record documentation can often be exported directly to the PA request, reducing administrative lag.

Step 3: Medical Necessity Review

The insurer's pharmacy benefits manager (PBM) or in-house clinical pharmacist reviews the submission against the plan's clinical coverage criteria. Most criteria align with AACE 2020 or ACOG/NOF guidelines. Denials at this stage typically cite:

• Inadequate documentation of prior bisphosphonate trial
• T-score above the plan's threshold (some plans require -3.0 rather than -2.5 for anabolic therapy initiation)
• Incomplete DXA report

Step 4: Appeals and Peer-to-Peer Review

If the PA is denied, the prescriber has the right to request a peer-to-peer review with the PBM's reviewing physician. Published data suggest peer-to-peer calls overturn roughly 30 to 50% of initial specialty drug denials in musculoskeletal conditions. A written appeal citing the specific AACE guideline language is advisable as a parallel track.

The AACE 2020 guidelines state directly: "Patients with very high fracture risk should receive anabolic therapy as initial treatment" [4]. That language can be quoted verbatim in an appeal letter when bisphosphonate step-therapy has been mandated.

Cost of Forteo and Financial Assistance Programs

List Price and Out-of-Pocket Exposure

The average wholesale price (AWP) of a Forteo 28-day prefilled pen was approximately $3,100 to $3,500 in late 2024. Without insurance or assistance, a full 24-month course would cost $74,000 to $84,000. Even with insurance, specialty-tier cost-sharing can run $300 to $700 per month during the deductible phase.

Lilly Cares Foundation (Patient Assistance Program)

Eli Lilly operates the Lilly Cares Foundation, which provides free Forteo to uninsured or underinsured patients who meet income eligibility criteria (generally at or below 400% of the federal poverty level). Applications are available at lillycares.com or through ChristianaCare's social work and financial counseling teams [8].

Lilly Forteo Savings Card

For commercially insured patients, the Lilly Forteo savings card can reduce out-of-pocket costs to as low as $5 to $25 per month for eligible patients. The savings card cannot be used by Medicare or Medicaid beneficiaries (federal anti-kickback statute restrictions apply).

Generic Teriparatide: Bonsity and Other Biosimilar-Adjacent Options

Teriparatide is a small peptide, not a biologic, so it follows standard small-molecule generic pathways. Alvogen's Bonsity (teriparatide injection 20 mcg) received FDA approval in 2021 and has been commercially available since late 2022 [9]. Generic teriparatide may carry a lower list price and a more favorable formulary tier on some plans. Patients at ChristianaCare pharmacies should ask specifically whether their plan prefers the generic over the brand, as formulary tier placement differs by plan year.

Alternatives to Forteo: What Insurers May Require First

Because step-therapy requirements are widespread, understanding the osteoporosis drug class hierarchy helps patients and prescribers plan ahead.

Bisphosphonates (First-Line Antiresorptives)

Alendronate (Fosamax), risedronate (Actonel), and zoledronic acid (Reclast) are generic and very low cost. The American College of Physicians 2017 guidance recommended bisphosphonates as first-line therapy for most postmenopausal women with osteoporosis, and most commercial PA criteria follow that logic [10]. A documented bisphosphonate trial of at least 12 months, or a documented contraindication such as esophageal disease, severe renal impairment (eGFR <35 mL/min), or osteonecrosis of the jaw, strengthens a teriparatide PA significantly.

Denosumab (Prolia)

Denosumab 60 mg every 6 months (Prolia) is a RANK-L inhibitor approved for postmenopausal osteoporosis. Some plans require denosumab trial before approving teriparatide; others accept bisphosphonate failure alone. The FREEDOM trial (N=7,868) showed denosumab reduced vertebral fracture risk by 68% over 36 months [11]. Patients who discontinue denosumab without transitioning to a bisphosphonate face rebound vertebral fractures, a clinical consideration that sometimes supports early teriparatide use in patients who are denosumab-intolerant.

Romosozumab (Evenity)

Romosozumab (Evenity, Amgen/UCB) is a sclerostin inhibitor with dual anabolic and antiresorptive effects, approved in 2019 for postmenopausal women at high fracture risk. The ARCH trial (N=4,093) showed romosozumab followed by alendronate reduced vertebral fractures by 48% versus alendronate alone at 24 months [12]. Romosozumab carries a black-box warning for cardiovascular risk and is contraindicated in patients with myocardial infarction or stroke within the preceding year. Its formulary position relative to teriparatide varies by plan; some payers treat them as therapeutic alternatives requiring prescriber justification for one over the other.

Practical Steps for ChristianaCare Patients Seeking Forteo Coverage

Getting Forteo covered at a ChristianaCare facility is achievable when the clinical case is well-documented. The sequence that most consistently leads to approval:

1. Obtain a current DXA scan (dual-energy X-ray absorptiometry) within the past 24 months. ChristianaCare's radiology department performs DXA at multiple outpatient sites in Delaware.
2. Have a ChristianaCare endocrinologist, rheumatologist, or metabolic bone specialist document fracture history and fracture risk formally in the medical record.
3. Confirm whether your plan requires bisphosphonate step-therapy and, if yes, document why that requirement should be waived (prior trial, contraindication, or very high fracture risk per AACE criteria).
4. Ask the prescriber's office to submit the PA with the DXA printout, FRAX score, fracture imaging, and a brief letter citing AACE 2020 or NOF guidelines.
5. If denied, request a peer-to-peer review within 5 business days of the denial notice to preserve appeal rights under most plan documents.
6. Apply simultaneously for the Lilly savings card or Lilly Cares assistance so the drug is available the day the PA clears.

What ChristianaCare Clinicians Look for Before Prescribing Teriparatide

ChristianaCare's endocrinology and rheumatology programs apply clinical criteria consistent with national guidelines before initiating teriparatide, independent of insurance requirements.

Contraindications That Preclude Prescribing

Teriparatide is contraindicated in patients with elevated baseline serum calcium (hypercalcemia), Paget's disease of bone, prior external beam radiation to the skeleton, unexplained alkaline phosphatase elevation (which may suggest Paget's or malignancy), and in patients under age 25 whose growth plates may still be open [1]. A pre-treatment serum calcium, comprehensive metabolic panel, and alkaline phosphatase level are standard before the first injection.

Monitoring During Treatment

During the 24-month treatment course, ChristianaCare clinicians typically schedule:

• Serum calcium 1 to 4 weeks after initiation (orthostatic hypotension and hypercalcemia are the most common early adverse effects)
• DXA at 12 months to document treatment response
• Transition planning at month 18 to 20, because stopping teriparatide without an antiresorptive follow-on leads to rapid bone loss

The Endocrine Society's 2019 clinical practice guidelines on osteoporosis specify: "After completing anabolic therapy, we recommend sequential antiresorptive therapy to maintain or further increase BMD gains" [13].