Does EmblemHealth Cover Forteo (Teriparatide)?

What Is Forteo and Why Does It Require Special Coverage Review?

Forteo (teriparatide) is a recombinant fragment of human parathyroid hormone (PTH 1-34) administered as a daily 20 mcg subcutaneous injection. The FDA approved it in November 2002 for postmenopausal women with osteoporosis at high fracture risk, men with primary or hypogonadal osteoporosis, and patients with glucocorticoid-induced osteoporosis. [1]

Its mechanism is genuinely distinct from antiresorptive agents. Rather than slowing bone breakdown, teriparatide stimulates new bone formation by activating osteoblasts. This anabolic effect makes it the appropriate choice when antiresorptive therapy has failed or when a patient presents with very severe bone loss.

Clinical Evidence Behind the Drug

The key Fracture Prevention Trial (N=1,637 postmenopausal women) showed teriparatide 20 mcg/day reduced new vertebral fracture risk by 65% versus placebo over a median of 21 months (relative risk 0.35, 95% CI 0.22 to 0.55, P<0.001). [2] Non-vertebral fragility fractures dropped by 53% in the same analysis. These are the numbers insurers see when evaluating medical necessity.

Why the List Price Triggers Prior Authorization

At roughly $3,300 per month, a standard 24-month course costs approximately $79,000 before rebates. Insurers classify drugs above a spend threshold as specialty medications and require prior authorization (PA) to verify that less-expensive antiresorptive agents were tried first. This is standard practice across commercial plans, not something unique to EmblemHealth.

The FDA's 2-Year Lifetime Limit

The FDA label limits cumulative teriparatide use to 2 years across a patient's lifetime. [1] That restriction, combined with the drug's cost, is why most payer PA criteria require documented severe osteoporosis or antiresorptive failure before approving the first fill.

How EmblemHealth's Formulary Works for Specialty Drugs

EmblemHealth operates several distinct plan products in New York. The main ones are HIP (Health Insurance Plan of Greater New York), GHI (Group Health Incorporated), and ConnectiCare (acquired in 2015). Each product may carry a different formulary, so the specific tier placement and PA criteria for Forteo can vary even within the same employer group.

Formulary Tiers

Most EmblemHealth commercial plans use a 4- or 5-tier formulary structure:

• Tier 1: Generic preferred drugs (lowest copay)
• Tier 2: Preferred brand drugs
• Tier 3: Non-preferred brand drugs
• Tier 4: Specialty preferred drugs
• Tier 5: Specialty non-preferred drugs (highest cost-sharing)

Forteo typically lands on Tier 4 or Tier 5. Member cost-sharing at the specialty tier commonly runs 20 to 40 percent coinsurance or a fixed copay of $150 to $500 per 28-day supply, though the exact amount depends on your employer's benefit design.

Where to Find Your Specific Formulary

EmblemHealth posts formularies on its website at emblemhealth.com. To look up Forteo:

1. Go to emblemhealth.com and select "Find a Drug."
2. Enter your plan ID or select your plan name.
3. Search "teriparatide" or "Forteo."
4. Review the tier, any PA indicators, and any step-therapy flags.

Always use the formulary effective for the current plan year, because tier placement can change on January 1.

Prior Authorization Criteria for Forteo Under EmblemHealth

Prior authorization is required for Forteo on virtually every EmblemHealth plan. The insurer bases its PA criteria on clinical guidelines published by the American Association of Clinical Endocrinology (AACE) and the Endocrine Society, then applies its own utilization-management overlay.

Typical Medical Necessity Requirements

EmblemHealth's PA criteria for teriparatide generally require documentation of all of the following:

1. Diagnosis of osteoporosis confirmed by dual-energy X-ray absorptiometry (DXA) with a T-score of -2.5 or below at the lumbar spine, femoral neck, or total hip, OR a documented fragility fracture.
2. High fracture risk as defined by FRAX 10-year probability exceeding the AACE intervention thresholds (major osteoporotic fracture probability greater than 20%, or hip fracture probability greater than 3%). [3]
3. Step therapy documentation showing at least 12 months of treatment with an oral bisphosphonate (alendronate 70 mg weekly or risedronate 35 mg weekly being the most common) with either intolerance, contraindication, or inadequate response defined as a new fragility fracture on therapy or continued significant bone loss on serial DXA.
4. Prescriber specialty of endocrinology, rheumatology, or orthopedics is preferred by some EmblemHealth plans, though primary care prescriptions are not categorically excluded.
5. Absence of contraindications including hypercalcemia, skeletal malignancy, Paget's disease, prior external beam or implant radiation to the skeleton, and pediatric patients with open epiphyses.

The framework above represents the HealthRX medical team's synthesis of AACE 2020 guidelines, FDA prescribing information, and typical commercial PA criteria. Individual EmblemHealth plan criteria may differ. Confirm with the plan's PA department (or the specialty pharmacy processing the claim) before submitting.

Step Therapy: What Counts as a Trial?

New York State's Step Therapy Act (effective January 2017) requires that insurer step-therapy protocols follow evidence-based standards and that providers can request a step-therapy exemption when the standard protocol is clinically inappropriate. [4] Under this law, EmblemHealth must grant an exemption if:

• The required step-therapy drug is contraindicated.
• The required drug caused a clinically significant adverse reaction previously.
• The required drug is expected to be ineffective based on the patient's clinical history.
• The patient already tried and failed the required drug under a prior plan.
• A physician documents that the required drug will cause harm.

Document contraindications thoroughly in the PA request. Esophageal disorders, for example, are a recognized contraindication to oral bisphosphonates and satisfy the exemption criteria.

Duration and Renewal

Initial PA approvals for Forteo commonly cover 6 months. Renewal typically requires documentation that the patient is tolerating the medication and that bone turnover markers (serum P1NP or CTX) or DXA results indicate response. The FDA lifetime limit of 2 years caps the total approved duration across all renewals.

Biosimilars and Alternatives That May Be Preferred

Bonsity (Teriparatide-ppfc)

The FDA approved Bonsity (teriparatide-ppfc, by Alvogen/Amneal) in June 2021 as a biosimilar to Forteo. [5] Some EmblemHealth plans have moved Bonsity to a preferred specialty tier, meaning lower cost-sharing than brand Forteo. If your plan lists Bonsity as preferred and Forteo as non-preferred, the PA criteria are generally identical, but your out-of-pocket cost may be meaningfully lower with Bonsity.

Tymlos (Abaloparatide)

Tymlos (abaloparatide 80 mcg/day, Radius Health) is a different PTH-related peptide analog approved in April 2017. [6] It carries a similar anabolic mechanism and the ACTIVE trial (N=2,463) showed a 43% reduction in new vertebral fractures versus placebo at 18 months. [7] EmblemHealth may prefer Tymlos over Forteo on some plans, or vice versa. Check your specific formulary.

Evenity (Romosozumab)

For patients with very high fracture risk, romosozumab (Evenity, Amgen) targets sclerostin to simultaneously stimulate bone formation and reduce resorption. The ARCH trial (N=4,093) showed romosozumab followed by alendronate reduced new vertebral fracture risk by 48% versus alendronate alone at 24 months. [8] Romosozumab carries an FDA boxed warning for cardiovascular events. EmblemHealth plans that have added Evenity to their formulary generally place it at the same specialty tier as Forteo.

Antiresorptive Agents at Lower Tiers

If a patient has not yet failed antiresorptive therapy, the following drugs are generally at lower tiers (Tier 1 or Tier 2) and have strong fracture data:

• Alendronate 70 mg weekly (generic): FIT trial (N=2,027) showed 47% reduction in hip fracture at 36 months. [9]
• Risedronate 35 mg weekly (generic): VERT-MN trial (N=1,226) showed 41% vertebral fracture reduction at 3 years. [10]
• Denosumab 60 mg every 6 months (Prolia): FREEDOM trial (N=7,808) showed 68% reduction in new vertebral fractures at 36 months. [11]

How to Submit a Prior Authorization Request to EmblemHealth

A well-constructed PA submission dramatically increases first-pass approval rates. The HealthRX medical team's internal review of PA submission patterns found that denials most commonly stem from missing DXA T-score documentation, missing FRAX scores, and absent step-therapy records.

Step-by-Step Submission Checklist

Step 1. Verify the PA requirement. Call EmblemHealth Provider Services at the number on the back of the member's card or log into the EmblemHealth provider portal. Confirm that PA is required for the specific plan and NDC.

Step 2. Gather clinical documentation. You need:

• Most recent DXA report with T-scores at lumbar spine and hip
• FRAX calculation printout (frax.shef.ac.uk)
• Documentation of prior bisphosphonate trial (dates, dose, duration, reason for discontinuation)
• Recent labs: serum calcium, 25-OH vitamin D, creatinine/GFR
• Prescriber's clinical note summarizing fracture risk and rationale for anabolic therapy

Step 3. Submit via the specialty pharmacy or the EmblemHealth PA portal. Forteo is usually dispensed through a specialty pharmacy (CVS Specialty, Accredo, or the network specialty pharmacy on your plan). Many specialty pharmacies will initiate and track the PA on behalf of the prescriber.

Step 4. Confirm receipt and timeline. EmblemHealth must respond to standard PA requests within 3 business days and urgent PA requests within 1 business day under New York State regulations.

Step 5. Document the authorization number. Store the PA reference number, approval date, expiration date, and approved quantity in the patient chart. Specialty pharmacy fills will fail at adjudication if the PA has expired.

What to Do If EmblemHealth Denies Forteo Coverage

Denials happen even with strong clinical documentation. Knowing the appeal pathway matters.

Internal Appeal

File an internal appeal within 60 days of receiving the denial notice. Submit a letter from the prescriber explaining why step therapy is inappropriate or why Forteo is medically necessary. Include peer-reviewed references such as the AACE 2020 Clinical Practice Guidelines, which state: "Anabolic therapy is recommended as initial treatment for patients at very high risk of fracture, including those with very low T-scores (below -3.0), multiple fractures, or failure of antiresorptive therapy." [3]

EmblemHealth must resolve standard internal appeals within 30 days. Expedited appeals (when the standard timeline would seriously jeopardize the patient's health) must be resolved within 72 hours.

External Appeal

If the internal appeal is denied, New York State allows an independent external appeal through the New York State Department of Financial Services. External appeals must be filed within 45 days of receiving the internal appeal denial. The external reviewer (an independent organization approved by the state) issues a binding decision. [12]

New York Step Therapy Exemption Request

As noted above, New York law provides a statutory exemption pathway separate from the standard appeal process. A prescriber who documents a clinical reason why step therapy is inappropriate can request this exemption simultaneously with or before filing a PA, potentially bypassing bisphosphonate trial requirements entirely when clinically justified. [4]

Cost and Patient Assistance Programs

Out-of-Pocket Estimates With EmblemHealth Coverage

With a specialty Tier 4 or Tier 5 benefit, monthly out-of-pocket costs for Forteo may range from $150 (fixed copay plan) to $800 or more (coinsurance plan without a cap). Annual out-of-pocket maximums under the ACA limit total cost-sharing; for 2025, the individual maximum is $9,200 for most plans.

Eli Lilly's Forteo Patient Assistance

Eli Lilly offers the Lilly Cares Foundation Patient Assistance Program for patients who meet income eligibility criteria (generally household income at or below 400% of the federal poverty level). The program may provide Forteo at no cost or reduced cost for uninsured or underinsured patients. Visit lilly.com or call 1-800-545-5979.

Lilly's Insulin Value Program and Specialty Copay Cards

Eli Lilly has offered copay assistance cards for Forteo that cap monthly patient cost-sharing at a fixed amount for commercially insured patients. These programs are subject to change and are not available to Medicare or Medicaid patients due to federal anti-kickback rules. Ask the specialty pharmacy at the time of dispensing whether a current copay card is available.

GoodRx and Mark Cuban Cost Plus Drugs

GoodRx discounts for brand Forteo are modest because no generic equivalent exists (only the biosimilar Bonsity). Mark Cuban's Cost Plus Drugs does not currently list teriparatide. Bonsity may carry a lower cash price than brand Forteo through specialty pharmacies.

Medicare and Medicaid Considerations

If a patient has EmblemHealth as secondary coverage over Medicare or Medicaid, the coverage analysis changes significantly.

Medicare Part D

Medicare Part D plans classify Forteo as a specialty-tier drug. The INFLATION REDUCTION ACT (IRA) 2022 provisions are phasing in a $2,000 annual out-of-pocket cap for Part D enrollees starting in 2025, which reduces but does not eliminate specialty-tier exposure. [13] The Low Income Subsidy (LIS/Extra Help) program eliminates most specialty-tier cost-sharing for qualifying Medicare patients.

Medicaid (New York Medicaid / EmblemHealth Medicaid Managed Care)

New York Medicaid covers teriparatide with PA under the New York State Medicaid preferred drug list. EmblemHealth administers several Medicaid managed care products in New York. Medicaid PA criteria generally mirror the commercial criteria described above but may have stricter step-therapy requirements given Medicaid's cost-control mandate.

Clinical Guidelines Supporting Forteo Use

The AACE/ACE 2020 Clinical Practice Guideline for the Diagnosis and Treatment of Postmenopausal Osteoporosis recommends anabolic therapy as a first-line option for patients at "very high fracture risk," defined as a T-score at or below -3.0, a FRAX major osteoporotic fracture probability exceeding 30%, or a history of multiple vertebral fractures. [3]

The Endocrine Society's 2019 Pharmacological Management of Osteoporosis in Postmenopausal Women Guideline similarly states that for women at very high fracture risk, anabolic agents such as teriparatide or abaloparatide are preferred over antiresorptive agents as initial therapy. [14] These guideline statements are directly quotable in PA appeal letters and carry significant weight with medical directors.

For men, the Endocrine Society's 2012 Osteoporosis in Men guideline (reaffirmed in subsequent updates) supports teriparatide use in men with severe osteoporosis or prior vertebral fracture. [15]

Practical Tips for Providers Prescribing Forteo to EmblemHealth Members

Getting the first PA approved, rather than working through a denial and appeal cycle, saves 2 to 4 weeks of delay for the patient. Several practices reliably improve first-pass approval rates.

Document FRAX Explicitly

Run a FRAX score at the time of the visit and paste the printout or numerical result directly into the PA request. Reviewers who see "major osteoporotic fracture probability: 34%" are less likely to issue a reflexive denial than reviewers who see "high fracture risk" without a number.

Reference the Guideline by Name

Citing "AACE 2020 Guideline recommendation for anabolic-first therapy at T-score -3.2" in the prescriber letter is more persuasive than a generic statement about medical necessity. PA medical directors are physicians who recognize guideline names.

Use the Specialty Pharmacy PA Support Team

CVS Specialty, Accredo, and other specialty pharmacies that dispense Forteo have dedicated PA teams experienced with EmblemHealth criteria. Engaging them early (at the time of the prescription, not after a denial) is the single most efficient step a prescriber's office can take.

Send Renewals 30 Days Early

PA approvals expire. A lapse in authorization causes a gap in therapy, which is clinically suboptimal given that bone turnover markers can rise within weeks of stopping teriparatide. Scheduling renewal submissions 30 days before expiration keeps therapy uninterrupted.