Does Highmark Cover Forteo (Teriparatide)?

What Is Forteo and Why Does Coverage Get Complicated?

Forteo is a daily self-injected form of recombinant human parathyroid hormone (teriparatide 20 mcg) that stimulates new bone formation rather than simply slowing bone breakdown. The FDA approved it in 2002 for postmenopausal women and men with osteoporosis at high fracture risk, and it remains one of the few anabolic agents available for severe cases. [1]

Because its monthly list price runs close to $3,200, every major insurer, including Highmark, places it on a high-cost specialty tier and wraps it in multiple coverage requirements. Those requirements exist precisely because lower-cost options such as alendronate (roughly $10/month generic) address most osteoporosis cases adequately.

Why Highmark Treats Forteo as a Specialty Drug

Specialty drugs are typically defined as medications that cost more than $600 per month, require special handling, or need close clinical monitoring. Forteo meets all three criteria. Highmark routes specialty drugs through designated specialty pharmacies, most commonly Accredo or Highmark's own pharmacy network, which adds a layer of logistics that does not apply to standard retail prescriptions.

The Anabolic vs. Antiresorptive Distinction

Most osteoporosis drugs, alendronate, risedronate, denosumab, are antiresorptive. They slow the cells that break bone down. Forteo is anabolic. It stimulates osteoblasts to build new bone. This distinction matters for coverage because insurers generally reserve anabolic therapy for patients who have already failed or cannot tolerate antiresorptive treatment, or who present with very high fracture risk at baseline.

In the FRACTURE trial (N=1,637), teriparatide reduced new vertebral fracture risk by 65% compared with placebo over 21 months (9.3% vs. 1.4% new fracture incidence, P<0.001). [2] That efficacy data is why physicians pursue coverage aggressively, and why insurers demand documented justification before approving it.

How Highmark Plans Are Structured: Commercial vs. Medicare

Highmark operates several distinct plan lines, and coverage rules differ across them. Knowing which plan you carry is the first step to understanding your Forteo benefit.

Highmark Commercial (Employer-Sponsored and Individual Plans)

Under commercial plans, Forteo typically appears on the specialty formulary at Tier 4 or Tier 5. Copays for specialty drugs on Highmark commercial plans commonly range from $100 to $350 per 28-day supply after the deductible is met, though exact figures vary by employer contract. Prior authorization is nearly universal. Step therapy requiring at least one bisphosphonate trial is standard on most commercial formularies as of 2025.

Highmark Medicare Advantage and Part D

Medicare Advantage (MA) plans offered through Highmark follow CMS guidelines, which permit step therapy for Part B and Part D drugs. Forteo under Part D plans is placed in the specialty tier, and cost-sharing can reach 25-33% of the drug's cost during the coverage gap. In 2025, the Inflation Reduction Act capped out-of-pocket Part D costs at $2,000 annually, which meaningfully limits exposure for high-cost drugs like Forteo. [3]

Under some Highmark MA plans, teriparatide may be billed under the medical benefit (Part B) when administered in a clinical setting, though home self-injection typically routes through Part D.

Highmark Blue Shield of Pennsylvania vs. Other Regional Plans

Highmark operates across Pennsylvania, Delaware, West Virginia, and northeastern New York through several Blue Cross Blue Shield affiliates. Formularies are not identical across these regions. A plan in Pittsburgh may have slightly different step therapy requirements than one in Wilmington. Always check the specific Summary of Benefits and Coverage (SBC) for your plan year at Highmark's online formulary lookup tool or call the member services number on your insurance card.

Prior Authorization: What Highmark Typically Requires

Prior authorization (PA) for Forteo under Highmark generally requires your physician to document several clinical criteria. The specific criteria can shift annually, but the following represent the typical requirements seen across Highmark commercial and Medicare plans as of 2024-2025.

Clinical Criteria Checklist

Most PA submissions for Forteo require all of the following:

• A confirmed diagnosis of osteoporosis with a DXA scan T-score at or below -2.5 at the lumbar spine, femoral neck, or total hip.
• Documentation of high fracture risk, which may include a FRAX score, a prior low-trauma vertebral or hip fracture, or multiple fragility fractures regardless of T-score.
• Evidence that the patient has either completed an adequate trial of a bisphosphonate (typically 12 months at a therapeutic dose) or has a documented contraindication or intolerance to bisphosphonates.
• Prescriber attestation that treatment duration will not exceed 24 cumulative months (the FDA-approved lifetime limit). [1]
• For postmenopausal women, confirmation that the patient is not pregnant and has appropriate calcium and vitamin D intake (typically 1,000-1,200 mg calcium daily and 600-800 IU vitamin D daily per the National Osteoporosis Foundation guidelines). [4]

Step Therapy: The Bisphosphonate Requirement

Step therapy is the most common reason PA requests are denied on the first submission. Highmark, like most commercial insurers, requires documented failure of or intolerance to at least one bisphosphonate before approving an anabolic agent. Alendronate 70 mg weekly is the most common first-step drug. Risedronate 35 mg weekly and ibandronate 150 mg monthly are also accepted in most cases.

"Failure" does not necessarily mean a fracture occurred on therapy. Documented intolerance (GI side effects, esophageal issues, inability to remain upright for 30 minutes post-dose) or contraindications such as severe renal impairment (creatinine clearance <35 mL/min) can satisfy step therapy requirements without a full 12-month trial.

Exceptions That Can Bypass Step Therapy

Certain clinical scenarios allow physicians to request a step therapy exception:

1. Very high fracture risk defined as a 10-year major osteoporotic fracture probability above 30% on FRAX, per American Association of Clinical Endocrinology (AACE) guidelines. [5]
2. Multiple vertebral fractures documented on spine imaging, even with T-score above -2.5.
3. Patients on long-term glucocorticoid therapy (prednisone 7.5 mg/day or more for 3 months or longer), a population in which anabolic therapy may be appropriate first-line per the American College of Rheumatology 2022 guidelines. [6]
4. Prior osteonecrosis of the jaw or atypical femoral fracture related to prior antiresorptive use.

How to Submit a Forteo PA to Highmark

The prescribing physician's office handles PA submission, but patients who understand the process can advocate more effectively.

Step-by-Step PA Process

1. Your physician submits a PA request through Highmark's provider portal or via fax using Highmark's specialty drug PA form. The request must include the ICD-10 code for osteoporosis (M81.0 for postmenopausal osteoporosis without fracture, M80.08X for vertebral fracture, or the appropriate code for the clinical presentation).
2. Highmark's pharmacy benefit manager (often Prime Therapeutics for commercial plans) reviews the request against clinical criteria. Review typically takes 3 to 5 business days for standard requests and 24 to 72 hours for urgent requests.
3. If approved, the PA is generally valid for 12 months and must be renewed annually for any continuation beyond the first year.
4. If denied, the denial letter must cite the specific clinical criteria not met. This letter is your roadmap for the appeal.

Documentation That Strengthens a PA Request

A strong PA packet typically includes the DXA report with T-scores, the FRAX calculation printout, clinic notes documenting fracture history, the bisphosphonate trial dates and reason for discontinuation or failure, and a letter of medical necessity from the prescriber. Practices that submit these documents together in the initial request see faster approvals with fewer follow-up requests for information.

What Happens After a Denial

Initial PA denials are common, but they are not final. Highmark, like all insurers operating under ACA and ERISA rules, must provide an internal appeal process, and most plans also offer an independent external review.

Internal Appeal

File the internal appeal within the timeframe specified in the denial letter, typically 180 days for commercial plans and 60 days for Medicare plans. The appeal should include any additional clinical documentation not submitted initially, such as updated FRAX calculations, specialist letters, or published clinical guidelines supporting anabolic therapy for the patient's specific risk profile.

The American Society for Bone and Mineral Research (ASBMR) and AACE have published position statements supporting early anabolic use in very-high-risk patients. Citing these directly in an appeal letter, with the guideline name and year, often carries weight with the clinical reviewers who evaluate appeals.

External Review

If the internal appeal is denied, ACA-compliant commercial plans allow you to request an independent external review by an accredited Independent Review Organization (IRO). The IRO's decision is binding on the insurer. Studies of external review outcomes across multiple insurers suggest that 40-60% of denied specialty drug claims are overturned through the appeal process when clinical documentation is thorough. [7]

Expedited Review for Urgent Cases

If your physician documents that the standard appeal timeline would seriously jeopardize your health, for instance after a recent hip or vertebral fracture, you can request an expedited internal appeal. Highmark must respond to expedited appeals within 72 hours under federal regulations.

Out-of-Pocket Costs With Highmark Coverage

Even with an approved PA, Forteo's cost-sharing can be significant.

Commercial Plan Cost-Sharing

On Highmark commercial plans, specialty tier cost-sharing structures vary by employer contract, but common structures include:

• A percentage coinsurance of 20-30% of the negotiated drug cost (not the list price). Highmark's negotiated rate for teriparatide is not publicly disclosed, but specialty drugs typically carry 20-40% discounts off list price.
• A flat specialty copay, which on some Highmark plans is set between $150 and $350 per 28-day supply.
• Out-of-pocket maximums on ACA-compliant plans cap at $9,450 for an individual in 2025, meaning your annual exposure is bounded.

Medicare Part D Cost-Sharing in 2025

Under the Inflation Reduction Act's 2025 changes, Medicare Part D beneficiaries face a $2,000 annual out-of-pocket cap. [3] For a drug with a list price near $3,200/month, this cap is likely to be reached by the second or third month of therapy, after which the drug costs the patient nothing for the remainder of the plan year.

Patient Assistance Programs

Eli Lilly's Lilly Cares Foundation provides Forteo at no cost to uninsured or underinsured patients who meet income eligibility criteria (generally at or below 400% of the federal poverty level). Even patients with insurance may qualify for Lilly's Forteo Savings Program, which can reduce commercial insurance copays to as low as $5 per month for eligible patients. Patients should call 1-800-545-5979 or visit Lilly's patient assistance portal to determine eligibility.

Generic Teriparatide: Does Highmark Prefer It Over Brand Forteo?

The FDA approved the first generic teriparatide (from Alvogen/Natco) in 2020, and biosimilar/generic versions have steadily expanded. Highmark commercial formularies increasingly place generic teriparatide at a lower tier than brand Forteo, or may require the generic as a condition of coverage under non-medical switching policies.

What This Means Practically

If Highmark approves teriparatide therapy, you may be approved for the generic rather than brand Forteo. Generic teriparatide contains the same 20 mcg dose of the same peptide sequence. The FDA's approval process for these formulations required demonstration of pharmaceutical equivalence. [8] Clinically, the outcomes data are from brand Forteo trials, so some physicians prefer to continue a patient on whichever formulation they started; others are comfortable with switching.

If your physician has a documented clinical reason to require brand Forteo specifically (for instance, device compatibility for patients with injection difficulties), a brand-necessary exception can be requested, though approval is not guaranteed.

Alternatives to Forteo That Highmark Covers More Readily

If Forteo coverage cannot be obtained, several alternatives occupy lower formulary tiers on most Highmark plans.

Antiresorptive First-Line Options

• Alendronate (generic): Tier 1 or 2 on virtually all Highmark plans. No PA required. Cost <$15/month generic.
• Risedronate (generic): Similar tier placement to alendronate.
• Denosumab (Prolia): Usually Tier 3-4, billed under medical benefit as an injection administered in office every 6 months. PA typically required, but step therapy requirements are less stringent than for Forteo.
• Zoledronic acid (Reclast): Annual IV infusion, often covered under medical benefit. PA commonly required.

Other Anabolic Agents

• Abaloparatide (Tymlos): A PTHrP analog with similar anabolic mechanism to teriparatide. ACTIVE trial (N=2,463) showed 86% vertebral fracture risk reduction vs. Placebo at 18 months. [9] Highmark coverage criteria are similar to Forteo, but some formularies tier Tymlos differently.
• Romosozumab (Evenity): A sclerostin inhibitor with both anabolic and antiresorptive properties. ARCH trial (N=4,093) showed 48% reduction in new vertebral fractures vs. Alendronate at 24 months. [10] Highmark PA criteria for romosozumab typically require similar fracture risk documentation as Forteo, with additional cardiovascular screening due to a boxed warning for increased cardiovascular risk.

How Physicians Can Improve Approval Rates

Prescribers writing for Forteo can take specific steps to improve first-pass approval rates with Highmark.

Optimizing the PA Letter

A letter of medical necessity should cite the specific T-score with the DXA date, the FRAX 10-year probability, the specific bisphosphonate tried with start and stop dates and reason for discontinuation, and the relevant guideline (AACE 2020, NOF Clinician's Guide) by name and year. Generic letters citing only "osteoporosis" without supporting data are the most common reason for initial denials.

The Endocrine Society's 2019 clinical practice guideline states: "We suggest anabolic therapy be considered before antiresorptive therapy in patients at very high fracture risk, defined as a recent fracture, very low T-score (<-3.0), or fractures on antiresorptive therapy." [11] Quoting this guideline language directly in a PA letter signals to the reviewing clinician that the prescription meets recognized standards of care.

Requesting Peer-to-Peer Review

Most Highmark PA denials include contact information for the Medical Director overseeing the denial. Requesting a peer-to-peer review call between the prescribing physician and the Highmark Medical Director resolves many denials without going through formal appeal. These calls typically last 15-20 minutes. Physicians who are prepared with T-score data, FRAX scores, fracture history, and guideline citations consistently report higher overturn rates than those who rely solely on the written appeal.

A Practical Decision Framework for Patients and Prescribers

Before submitting a PA for Forteo, work through this sequence:

1. Confirm the clinical indication meets Highmark's documented criteria (T-score, fracture history, FRAX score).
2. Verify the bisphosphonate trial is documented in the medical record with clear start/stop dates and reason for stopping.
3. Check the current plan year's formulary at Highmark's member portal to confirm Forteo's tier and PA requirements, as these can change January 1 of each plan year.
4. Assemble the full PA documentation packet before submission rather than responding piecemeal to information requests.
5. If denied, request the peer-to-peer review before filing the formal written appeal.
6. If the peer-to-peer review does not resolve the denial, file the written internal appeal with all guideline citations within the stated deadline.
7. If the internal appeal fails, proceed to external independent review.
8. Simultaneously, contact Eli Lilly's patient assistance program to initiate a bridge supply while the appeal is pending, so treatment is not interrupted.