Does Gateway Health Plan Cover Forteo?

Gateway Health Plan's Formulary Status for Forteo

Gateway Health Plan lists Forteo (teriparatide) on its formulary as a covered specialty medication for the treatment of osteoporosis. The drug sits on the specialty tier, which means higher cost-sharing compared to generic oral medications and mandatory prior authorization before a pharmacy will dispense it.

Medicaid Managed Care vs. Medicare Advantage

Gateway operates two primary product lines in Pennsylvania. Its Medicaid managed care plans follow the Pennsylvania Department of Human Services preferred drug list, which includes teriparatide with prior authorization [1]. Medicaid members generally face nominal copays of $0 to $3 per prescription under federal cost-sharing limits.

Gateway's Medicare Advantage plans place Forteo on Tier 4 or Tier 5 (specialty). The Centers for Medicare & Medicaid Services (CMS) requires Medicare Part D plans to cover all FDA-approved osteoporosis drugs, but plans retain discretion over tier placement and utilization management tools [2]. That means the drug is accessible, but the path to getting it filled involves paperwork.

How to Confirm Your Specific Plan

Formulary details change each plan year. Call the member services number on the back of your Gateway ID card or log in to the Gateway Health Plan member portal. Ask specifically whether teriparatide carries prior authorization, step therapy, or quantity limits on your current plan document.

Prior Authorization Criteria for Forteo on Gateway

Gateway Health Plan requires prior authorization for Forteo across all product lines. The prescribing clinician must submit clinical documentation proving the patient meets specific medical necessity criteria before the pharmacy will process the claim.

Clinical Documentation Gateway Expects

A typical prior authorization request for teriparatide on a Medicaid managed care or Medicare Advantage plan requires the following [3]:

• A confirmed diagnosis of osteoporosis with a dual-energy X-ray absorptiometry (DXA) T-score of −2.5 or lower at the lumbar spine, femoral neck, or total hip.
• Documentation of at least one fragility fracture (vertebral, hip, or other non-traumatic fracture), OR a history of inadequate response to or intolerance of an oral bisphosphonate taken for at least 12 months.
• Lab results ruling out secondary causes of bone loss, including serum calcium, 25-hydroxyvitamin D, and thyroid-stimulating hormone (TSH) levels.
• Confirmation that the patient has no contraindications to teriparatide, such as Paget disease of bone, unexplained alkaline phosphatase elevation, prior skeletal radiation therapy, open epiphyses, or pre-existing hypercalcemia.

Step Therapy Requirements

Gateway follows step therapy protocols consistent with most commercial and government payers. The American Association of Clinical Endocrinology (AACE) 2020 guidelines recommend bisphosphonates as first-line therapy for most patients with osteoporosis [4]. Gateway aligns with this by requiring documentation that the patient tried alendronate, risedronate, or another oral bisphosphonate before approving an anabolic agent like Forteo.

The step therapy requirement can be bypassed if the prescriber documents contraindications to bisphosphonates, such as esophageal disorders (achalasia, stricture, Barrett esophagus), chronic kidney disease with estimated GFR <30 mL/min, or a history of atypical femoral fracture.

What Does Forteo Cost Through Gateway Health Plan?

Out-of-pocket costs vary significantly depending on your Gateway plan type, income level, and whether you qualify for low-income subsidies or the Eli Lilly Forteo Savings Card program.

Medicaid Managed Care Cost Sharing

Pennsylvania Medicaid limits prescription copays by federal regulation. For most Medicaid beneficiaries enrolled in Gateway, the copay for Forteo is $0 to $3 per 28-day supply [5]. No deductible applies. This makes Gateway Medicaid one of the least expensive pathways to teriparatide for eligible patients.

Medicare Advantage Cost Sharing

On Gateway's Medicare Advantage Part D plans, Forteo falls under the specialty tier. After the annual Part D deductible ($590 in 2026 for standard plans), members typically pay 25% to 33% coinsurance until they reach the catastrophic coverage threshold [2]. At Forteo's wholesale acquisition cost of approximately $3,800 per 28-day pen, a 25% coinsurance translates to roughly $950 per month before any manufacturer discount or Extra Help subsidy.

The Inflation Reduction Act's $2,000 annual out-of-pocket cap on Part D spending, fully in effect since 2025, means Gateway Medicare Advantage members will not pay more than $2,000 total across all Part D drugs in a calendar year [6]. For a patient whose only specialty medication is Forteo, the effective monthly cost averages out to $167 or less once the cap is reached.

Reducing Your Costs

Eli Lilly offers the Forteo Savings Card for commercially insured patients, which can reduce copays to as little as $4 per month. This card does not apply to Medicaid or Medicare beneficiaries. For Medicare patients, the Medicare Extra Help (Low-Income Subsidy) program can reduce copays to $4.50 to $11.20 per prescription in 2026 [2].

Clinical Evidence Supporting Forteo for Osteoporosis

Forteo (teriparatide) is the most-studied anabolic osteoporosis agent, with over two decades of clinical trial and real-world data. Payers like Gateway base their coverage criteria on this evidence.

The Fracture Prevention Trial

The key trial that led to Forteo's FDA approval enrolled 1,637 postmenopausal women with prior vertebral fractures. Over a median of 21 months, teriparatide 20 mcg/day reduced new vertebral fractures by 65% and non-vertebral fractures by 53% compared to placebo [7]. The number needed to treat (NNT) to prevent one vertebral fracture was 11, making it one of the more effective osteoporosis interventions available.

Head-to-Head Data Against Bisphosphonates

The VERO trial (N=1,360) compared teriparatide to risedronate in postmenopausal women with severe osteoporosis. At 24 months, teriparatide reduced new vertebral fractures by 56% relative to risedronate (HR 0.44, 95% CI 0.29 to 0.68, P<0.001) [8]. This trial is frequently cited in prior authorization appeals because it demonstrates that teriparatide provides a measurable benefit over bisphosphonates in high-risk patients.

What Guidelines Say

The Endocrine Society's 2019 guideline on pharmacological management of osteoporosis states: "We suggest teriparatide or abaloparatide treatment for postmenopausal women at very high risk of fracture, such as those with severe or multiple vertebral fractures" [9]. The AACE/ACE 2020 guideline similarly recommends anabolic therapy as initial treatment in patients with very high fracture risk, defined as a T-score ≤ −3.0, a recent fracture within 12 months, or fractures while on approved osteoporosis therapy [4].

Dr. Michael McClung, founding director of the Oregon Osteoporosis Center, noted in a 2020 review published in The Journal of Clinical Endocrinology & Metabolism: "The concept of starting with anabolic therapy and then consolidating gains with an antiresorptive represents a approach shift in how we should sequence osteoporosis treatments" [10].

How to Get Forteo Approved by Gateway Health Plan

The prior authorization process can feel bureaucratic. A clear, well-documented submission reduces the chance of denial and speeds up the approval timeline.

Step 1: Prescriber Submits the PA Request

Your physician, nurse practitioner, or physician assistant submits a prior authorization form to Gateway. Most Gateway plans accept electronic PA submissions through CoverMyMeds or a similar platform. The form requires the clinical data described above: DXA scores, fracture history, bisphosphonate trial history, and relevant lab values.

Step 2: Gateway Reviews Within 72 Hours

For standard (non-urgent) requests, Gateway must issue a coverage determination within 72 hours under Pennsylvania Medicaid regulations. Medicare Advantage standard requests follow CMS timelines of 72 hours as well [2]. Urgent or expedited requests (for example, a patient discharged from the hospital after a hip fracture) must be reviewed within 24 hours.

Step 3: If Approved, Fill at a Specialty Pharmacy

Gateway routes Forteo through its specialty pharmacy network. The medication ships directly to your home in a temperature-controlled package. The pen must be refrigerated at 36°F to 46°F (2°C to 8°C) and is self-administered as a daily subcutaneous injection in the thigh or abdomen.

Step 4: If Denied, File an Appeal

Denials happen. Common reasons include missing documentation, insufficient bisphosphonate trial duration, or a DXA T-score above the plan's threshold. You have the right to appeal. Gateway's internal appeal process involves a physician peer reviewer who re-evaluates the clinical case. If the internal appeal fails, Medicaid members can request a fair hearing through the Pennsylvania Department of Human Services, and Medicare Advantage members can escalate to an Independent Review Entity (IRE) [11].

Alternatives to Forteo Covered by Gateway

If Forteo is denied or cost-prohibitive, several other osteoporosis treatments may be covered under Gateway's formulary with fewer restrictions.

Oral Bisphosphonates

Alendronate (generic Fosamax) and risedronate (generic Actonel) are first-line and sit on the lowest formulary tiers. Gateway covers these with no prior authorization on most plans. Weekly alendronate 70 mg costs as little as $4 per month at retail pharmacies.

Denosumab (Prolia)

Denosumab is a RANK ligand inhibitor given as a subcutaneous injection every six months. The FREEDOM trial (N=7,868) showed denosumab reduced vertebral fractures by 68%, hip fractures by 40%, and non-vertebral fractures by 20% over three years [12]. Gateway typically covers denosumab on the specialty tier with prior authorization. It is an antiresorptive, not an anabolic agent, so it serves a different role in treatment sequencing.

Abaloparatide (Tymlos)

Abaloparatide is the other FDA-approved anabolic agent. The ACTIVE trial (N=2,463) demonstrated a 86% reduction in new vertebral fractures compared to placebo at 18 months [13]. Gateway may cover abaloparatide as an alternative anabolic option, though it carries similar prior authorization and step therapy requirements as Forteo. Some plans consider abaloparatide and teriparatide interchangeable for formulary purposes.

Zoledronic Acid (Reclast)

Zoledronic acid is an intravenous bisphosphonate given once yearly. The HORIZON trial (N=7,765) showed a 70% reduction in vertebral fractures and a 41% reduction in hip fractures over three years [14]. Because it bypasses the GI tract entirely, it avoids the esophageal side effects that make oral bisphosphonates unsuitable for some patients. Gateway covers zoledronic acid as a medical benefit (not pharmacy benefit), meaning it is billed through the provider's office rather than a pharmacy claim.

Romosozumab (Evenity)

Romosozumab is a sclerostin inhibitor with both anabolic and antiresorptive properties. The ARCH trial (N=4,093) showed romosozumab followed by alendronate reduced vertebral fractures by 48% compared to alendronate alone over 24 months [15]. Gateway may require a separate prior authorization pathway for romosozumab, and it carries a black box warning regarding cardiovascular risk. Patients with a history of myocardial infarction or stroke within the preceding year are not candidates.

Duration of Treatment and What Comes After

The FDA limits teriparatide use to 24 months based on the original preclinical finding of osteosarcoma in rats exposed to high-dose, long-duration treatment. Human data has not confirmed this risk. A 15-year post-marketing surveillance study found no increased osteosarcoma incidence among teriparatide-treated patients [16].

The Sequencing Question

Bone density gains from teriparatide are lost within 12 to 24 months of discontinuation if no antiresorptive is started afterward [9]. The DATA-Switch trial showed that women who received teriparatide followed by denosumab achieved the greatest BMD gains at the spine and hip compared to any other treatment sequence [17].

Your prescriber should have a plan for follow-on therapy before your 24-month course ends. Most patients transition to denosumab or a bisphosphonate. Gateway's formulary supports this transition, as all major antiresorptive classes are covered.

Monitoring During Treatment

The Endocrine Society recommends checking serum calcium one month after starting teriparatide, then DXA at 12 and 24 months to assess BMD response [9]. Procollagen type 1 N-terminal propeptide (P1NP), a bone formation marker, rises within one month of starting therapy and can confirm the drug is working before DXA changes become apparent.

Frequently Asked Questions