Does Humana Cover Forteo (Teriparatide)?

What Is Forteo and Why Does Coverage Get Complicated?

Forteo is a recombinant form of human parathyroid hormone (PTH 1-34) that stimulates new bone formation rather than simply slowing bone loss. The FDA approved teriparatide 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. The full prescribing information is on the FDA accessdata portal.

Why Insurers Require Prior Authorization

Because teriparatide costs roughly $2,800, $3,200 per monthly pen at retail, insurers place it in specialty tiers and gate access behind prior authorization (PA). Humana, like most payers, uses the FDA label and clinical guidelines from the American Association of Clinical Endocrinologists (AACE) and the Endocrine Society to define who qualifies. AACE's 2020 clinical practice guidelines specify that anabolic agents like teriparatide are first-line only in patients with very high fracture risk, defined as a T-score at or below -3.0, a prior vertebral or hip fracture, or multiple fractures combined with low bone density.

Anabolic vs. Antiresorptive: Why It Matters for Coverage

Most osteoporosis drugs (alendronate, risedronate, zoledronic acid, denosumab) are antiresorptive. They slow the breakdown of existing bone. Teriparatide actually builds new bone by activating osteoblasts. Because anabolic therapy is more expensive and reserved for severe disease, Humana's medical policy mirrors the clinical hierarchy: try antiresorptive agents first, document failure or intolerance, then request teriparatide. This step-therapy requirement is the most common reason initial PA requests are denied.

How Humana Organizes Its Formularies

Humana operates several distinct plan types, and formulary placement varies across them.

Medicare Advantage Plans (HMO, PPO, PFFS)

Most Humana Medicare Advantage plans use a 5-tier formulary. Specialty drugs like Forteo sit at Tier 4 (preferred specialty) or Tier 5 (non-preferred specialty). Cost-sharing at Tier 5 can reach 33% coinsurance after the deductible, which translates to roughly $900, $1,050 per month out of pocket before the catastrophic phase of Medicare Part D kicks in.

The Inflation Reduction Act (IRA) of 2022 capped out-of-pocket drug costs for Medicare beneficiaries at $2,000 per calendar year starting in 2025. The Centers for Medicare and Medicaid Services summarizes the IRA drug-price provisions here. For a patient filling Forteo at Tier 5 coinsurance, the $2,000 cap means the drug effectively becomes free for the remainder of the year once that threshold is crossed. This is a meaningful change from prior years.

Humana Commercial and Employer Plans

Commercial formularies are negotiated independently with each employer group. Forteo may appear at Tier 3, Tier 4, or require a medical benefit carve-out through the employer's specialty pharmacy. If your Humana card came through your employer, you must check the Summary of Benefits and Coverage (SBC) document or call the number on the back of the card. Coverage terms differ substantially from Medicare Advantage.

Humana Medicaid (Managed Medicaid States)

In states where Humana manages Medicaid benefits (Kentucky, Ohio, and others), Forteo coverage is subject to state pharmacy and therapeutics (P&T) committee decisions. Medicaid programs often restrict teriparatide to patients with documented fragility fractures or T-scores at or below -2.5 with at least one additional clinical risk factor.

Prior Authorization Criteria: What Humana Typically Requires

Prior authorization for Forteo at Humana generally requires documentation of all of the following:

• A dual-energy X-ray absorptiometry (DXA) scan result with a T-score of -2.5 or lower at the spine, hip, or femoral neck, or a T-score of -1.0 or lower in a patient with a documented fragility fracture.
• An adequate trial of at least one antiresorptive agent (most commonly alendronate 70 mg weekly for a minimum of 12 months) with either documented bone loss on follow-up DXA, a new fracture during therapy, or a medically documented intolerance.
• The prescribing physician's specialty and National Provider Identifier (NPI). Humana occasionally requires the prescriber to be an endocrinologist, rheumatologist, or orthopedic specialist, though primary care physicians can prescribe if documentation is thorough.
• Confirmation that the patient does not have any FDA black-box contraindications: Paget disease of bone, unexplained alkaline phosphatase elevation, prior radiation therapy to the skeleton, bone metastases, or hypercalcemia.

The FDA black-box warning for teriparatide regarding osteosarcoma risk in animal studies is detailed in section 5.1 of the prescribing information. Humana's PA form will ask the prescriber to attest that none of these contraindications exist.

How Long Prior Authorization Takes

Most PA decisions from Humana arrive within 72 hours for non-urgent requests. Urgent requests (defined as a situation where delay could seriously jeopardize health) must be processed within 24 hours under CMS rules for Medicare Advantage plans. CMS Part D prior authorization requirements are codified at 42 CFR 423.568.

If the PA is approved, it is typically valid for 12 months, after which re-authorization is required. Given the FDA's 24-month lifetime limit on teriparatide, a patient will likely need one or two PA cycles in total.

What the Clinical Evidence Says About Who Needs Teriparatide

Understanding the evidence helps you make the strongest possible case for PA approval.

Fracture Risk Reduction Data

The key Fracture Prevention Trial (N=1,637) published in the New England Journal of Medicine demonstrated that teriparatide 20 mcg/day reduced new vertebral fractures by 65% (9.3% placebo vs. 3.2% teriparatide, relative risk 0.35) and new non-vertebral fragility fractures by 53% over a median of 21 months. (Neer et al., NEJM 2001.) These numbers are substantially larger than the fracture-reduction seen with bisphosphonates in equivalent high-risk populations.

AACE Risk Stratification

AACE's 2020 guidelines stratify osteoporosis patients into high and very high fracture risk categories. Patients classified as very high risk, defined as a T-score at or below -3.0, a recent fracture (within 12 months), fractures during antiresorptive therapy, or very high FRAX scores, are recommended to start with an anabolic agent rather than undergoing step therapy at all. The AACE clinical algorithm is summarized in the 2020 guidelines document. Including this classification explicitly in the PA request can overcome a step-therapy denial.

Glucocorticoid-Induced Osteoporosis

For patients on long-term glucocorticoid therapy (prednisone-equivalent dose of 7.5 mg/day or higher for 3 or more months), teriparatide is particularly well-supported. A head-to-head trial (Saag et al., NEJM 2007, N=428) showed teriparatide produced significantly greater increases in lumbar spine BMD (+7.2%) compared to alendronate (+3.4%) over 18 months in glucocorticoid-treated patients, with fewer new vertebral fractures. (Saag et al., NEJM 2007.) If a patient is on chronic steroids, the prescriber should document cumulative dose and duration prominently in the PA submission.

How to Submit a Prior Authorization Request to Humana

The process has several steps. Getting each one right the first time reduces delays substantially.

Step 1: Confirm the Correct Plan and Formulary

Log into MyHumana at humana.com or call the member services number on the card. Confirm whether Forteo (NDC 00002-7140-01 for the standard pen) is listed on the formulary and at what tier. If it is not listed, you may need to request a formulary exception rather than a standard PA.

Step 2: Gather Clinical Documentation

Collect the DXA report (with T-scores at each site), records of prior bisphosphonate therapy including dates and doses, any fracture imaging or radiology reports, a current medication list, and the prescriber's signed letter of medical necessity. The letter should explicitly reference the AACE 2020 very-high-risk criteria or the FDA-approved indication that applies.

Step 3: Submit via Humana's Provider Portal or Fax

Prescribers submit PA requests through Humana's CoverMyMeds integration or directly at providerportal.humana.com. Fax submission is still accepted at the specialty pharmacy PA fax lines printed on the Humana formulary document. Keep a fax confirmation receipt; it is your proof of timely submission if a dispute arises.

Step 4: Track Status and Respond to Additional Information Requests

Humana may issue an Additional Information Request (AIR) asking for lab values (serum calcium, alkaline phosphatase, 25-OH vitamin D) or additional fracture history. Responding within 5 business days is standard; delays beyond that can trigger an automatic denial.

What to Do If Humana Denies Coverage

Denials happen. A first-level denial is not the end of the road.

Internal Appeal (Level 1)

File a Level 1 Internal Appeal within 60 days of receiving the denial notice. Submit every piece of clinical documentation again, plus a physician attestation letter. For Medicare Advantage plans, CMS requires Humana to resolve standard internal appeals within 60 days and expedited appeals within 72 hours. Include the AACE guideline language and the Neer et al. Fracture data to establish medical necessity.

External Review (Level 2 and Beyond)

If the internal appeal fails, request an Independent Review Organization (IRO) review. For Medicare Advantage members, this goes to the Medicare Appeals Council. For commercial plan members, state external review laws apply. In most states, the IRO must issue a decision within 45 days for standard reviews and 72 hours for urgent reviews.

Peer-to-Peer Review

Before filing a formal appeal, the prescribing physician should always request a peer-to-peer review with Humana's medical director. This is an informal phone call, typically 15 to 30 minutes, where the physician presents the clinical case directly. Success rates for peer-to-peer reviews are not publicly reported by Humana, but in clinical practice, a thorough presentation of AACE very-high-risk criteria frequently reverses an initial step-therapy denial.

Alternatives If Coverage Is Denied or Cost-Sharing Is Prohibitive

Several pathways exist when PA is denied or cost-sharing is unaffordable.

Lilly Cares Patient Assistance Program

Eli Lilly operates the Lilly Cares Foundation for patients who cannot afford Forteo. Eligibility generally requires household income at or below 400% of the federal poverty level and lack of adequate prescription coverage. Applications are available by calling 1-800-545-5979 or at lillycares.com.

Generic Teriparatide

The FDA approved the first generic teriparatide (Bonsity, by TransCon Pharmaceuticals) in 2021. The FDA approval letter is accessible at accessdata.fda.gov. Generics may be placed at a lower tier on Humana formularies than brand Forteo, potentially reducing cost-sharing by 20 to 40%. Always check whether Humana's formulary distinguishes between the brand and the generic at the point of PA submission.

Romosozumab (Evenity) as an Alternative Anabolic Agent

If teriparatide is specifically excluded from a plan but anabolic therapy is medically necessary, romosozumab (Evenity, 210 mg subcutaneous monthly for 12 months) is the other FDA-approved anabolic option. The FRAME trial (N=7,180) showed romosozumab reduced vertebral fractures by 73% over 12 months vs. Placebo. (Cosman et al., NEJM 2016.) Its formulary placement on Humana plans differs from teriparatide, and some plans cover one but not the other. Checking both simultaneously can save time.

Denosumab (Prolia) as a High-Efficacy Antiresorptive

For patients who cannot access anabolic therapy, denosumab 60 mg every 6 months remains a high-efficacy antiresorptive option. The FREEDOM trial (N=7,868) showed denosumab reduced new vertebral fractures by 68% and hip fractures by 40% over 36 months. (Cummings et al., NEJM 2009.) Denosumab is typically placed at Tier 3 or Tier 4 on Humana formularies and may face less stringent step-therapy requirements.

Frequently Asked Questions