Does Priority Health 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) approved by the FDA in 2002 for the treatment of osteoporosis in postmenopausal women, men, and patients with glucocorticoid-induced osteoporosis who are at high fracture risk [1]. Unlike bisphosphonates, which slow bone resorption, teriparatide works by stimulating new bone formation, producing measurable increases in bone mineral density (BMD) within 3 to 6 months of daily 20 mcg subcutaneous injection [2].

Because Forteo is a specialty-tier injectable with a high list price and a 2-year lifetime cap on use, insurers including Priority Health apply rigorous medical-necessity criteria before approving it. The FDA label itself states the drug "should not be used for more than 2 years during a patient's lifetime" based on osteosarcoma risk data from rat studies at suprapharmacological doses [1].

How Teriparatide Differs From Antiresorptive Drugs

Bisphosphonates such as alendronate 70 mg weekly or risedronate 35 mg weekly reduce fracture risk by slowing osteoclast activity. Teriparatide does the opposite: it stimulates osteoblasts to build new bone matrix. In the key Fracture Prevention Trial (N=1,637), teriparatide 20 mcg/day reduced new vertebral fractures by 65% and non-vertebral fragility fractures by 53% compared with placebo over an 18-month median follow-up [3].

FDA Approval and Labeled Indications

The FDA approves teriparatide specifically for postmenopausal women with osteoporosis at high fracture risk, men with primary or hypogonadal osteoporosis at high fracture risk, and men and women with glucocorticoid-induced osteoporosis [1]. Priority Health's prior authorization criteria typically mirror these labeled indications closely, so prescriptions that fall squarely within FDA labeling have a stronger approval pathway.

Does Priority Health Cover Forteo on Its Formulary?

Priority Health, a Michigan-based health plan serving roughly 1.2 million members, does include teriparatide on select drug formularies, but placement and coverage conditions vary by plan type.

Commercial (Employer-Sponsored) Plans

On most Priority Health commercial formularies, Forteo sits at Tier 4 or Tier 5 (specialty). A prior authorization request must be submitted by the prescribing physician before dispensing. Step therapy requirements typically mandate that the patient has tried and failed, or has a documented contraindication to, at least one oral bisphosphonate for a minimum of 6 months. Failure is generally defined as a new fragility fracture while on therapy or an inability to tolerate the drug due to gastrointestinal adverse effects.

Medicare Advantage Plans

Priority Health administers several Medicare Advantage (MA) plans in Michigan. Federal rules under CMS require MA plans to cover drugs in the same drug classes as Medicare Part D, but formulary placement and cost-sharing still vary. On most Priority Health MA formularies reviewed for 2024 to 2025, teriparatide appears in the specialty tier with a required prior authorization and, in many cases, a step therapy protocol identical to the commercial plan requirements. CMS guidelines on step therapy for Part B and Part D drugs were updated in 2019 and give MA plans the authority to require step therapy before approving specialty drugs [4].

Medicaid (Priority Health Medicaid/MI Health Link)

Priority Health manages Medicaid lines of business in Michigan. Michigan Medicaid's Preferred Drug List (PDL) places teriparatide in a non-preferred specialty category. Coverage is available with prior authorization demonstrating medical necessity, but the step therapy bar is often higher, requiring documented failure of two bisphosphonates before anabolic therapy is approved.

Prior Authorization Criteria: What Priority Health Typically Requires

Prior authorization (PA) for Forteo under Priority Health generally requires the prescriber to document all of the following. The specific criteria can change annually, so always request the current PA criteria letter from Priority Health's pharmacy department.

Diagnosis and Bone Density Documentation

Priority Health typically requires a dual-energy X-ray absorptiometry (DXA) scan confirming at least one of the following: a T-score of -2.5 or below at the lumbar spine, total hip, or femoral neck; a T-score between -1.0 and -2.5 with at least one prior low-trauma (fragility) fracture; or a FRAX 10-year probability of major osteoporotic fracture of 20% or higher, or hip fracture probability of 3% or higher, consistent with National Osteoporosis Foundation guidelines [5].

Step Therapy Documentation

The prescriber must confirm the patient received an adequate trial of a bisphosphonate. "Adequate trial" is generally defined as at least 6 consecutive months at a therapeutic dose. If the patient could not complete this trial, documentation of a specific contraindication is required. Accepted contraindications include severe gastroesophageal reflux disease unresponsive to treatment, esophageal motility disorders, renal impairment with eGFR <30 mL/min/1.73m², or a documented history of bisphosphonate-related osteonecrosis of the jaw.

High-Risk Features That Strengthen the PA Submission

Including any of the following in the PA letter substantially increases approval odds: a prior hip or vertebral fracture (which raises the patient's 10-year fracture probability substantially regardless of T-score); glucocorticoid use of 5 mg/day or more of prednisone equivalent for 3 or more months; documented secondary osteoporosis from conditions such as celiac disease, primary hyperparathyroidism, or hypogonadism; and a recent DXA showing continued BMD decline despite antiresorptive therapy.

The HealthRX PA Submission Framework for Forteo recommends organizing the prior authorization letter into four labeled sections: (1) Diagnosis with DXA T-scores and FRAX score, (2) Prior treatment history with start/stop dates and specific drugs, (3) Reason for step therapy failure or contraindication with clinical notes, and (4) High-risk features justifying anabolic rather than antiresorptive therapy. Physicians who use this structure report fewer round-trip requests for additional information from the Priority Health pharmacy team.

How to Submit a Prior Authorization for Forteo Through Priority Health

Step 1: Gather Clinical Documentation

Before submitting, collect the most recent DXA report (within 24 months), FRAX score calculation, office visit notes documenting osteoporosis diagnosis, records of prior bisphosphonate prescriptions with fill dates from the pharmacy, and any imaging confirming fractures.

Step 2: Complete the PA Request Form

Priority Health accepts PA requests via its online provider portal, by fax, or through the prescriber's electronic health record if integrated. The specialty pharmacy dispensing Forteo (often AllianceRx Walgreens Prime or Accredo for Priority Health specialty contracts) may also initiate the PA on the prescriber's behalf.

Step 3: Allow Standard Processing Time

Priority Health is required under Michigan insurance regulations to process non-urgent PA requests within 14 calendar days. Urgent requests (defined as cases where the standard timeline could jeopardize the patient's health) must be processed within 72 hours. Prescribers should mark the request urgent if the patient has had a recent fracture or is at imminent fall risk.

Step 4: Respond to Additional Information Requests

If Priority Health's pharmacy reviewers request additional clinical information, the prescriber typically has 14 days to respond before the request is administratively closed. Providing complete documentation the first time reduces this risk significantly.

What Happens If Priority Health Denies Forteo Coverage?

A denial is not the end of the road. Priority Health, like all Michigan-regulated insurers, must provide a written denial notice stating the specific clinical reason and the appeals process.

Level 1 Internal Appeal

The first step is an internal appeal filed directly with Priority Health. The prescriber or patient must submit the appeal within 180 days of the denial notice. A new clinical reviewer, who was not involved in the original denial, must review the case. Priority Health must resolve standard internal appeals within 30 days and expedited appeals within 72 hours.

External Independent Medical Review

If the internal appeal is denied, Michigan law and the Affordable Care Act give patients the right to an external independent medical review (IMR). An independent organization reviews the clinical evidence against accepted medical standards. For osteoporosis drugs, IMR reviewers frequently cite American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) 2020 clinical practice guidelines, which designate teriparatide as a first-line agent for patients with very high fracture risk, defined as a recent fracture, T-score below -3.0, or multiple risk factors [6].

Peer-to-Peer Review

Before or during the internal appeal, the prescriber can request a peer-to-peer review call with Priority Health's medical director or pharmacy reviewer. Endocrinologists and rheumatologists report higher success rates in peer-to-peer reviews when they lead with fracture history, FRAX scores, and the AACE guideline language designating anabolic therapy as appropriate first-line treatment for very-high-risk patients [6].

Cost of Forteo Without Insurance Approval

Without coverage, the average retail price of one Forteo pen (delivering 28 daily doses) runs between $3,000 and $3,500 at major U.S. Pharmacies as of early 2025. A full 24-month course at that rate would cost approximately $78,000 to $91,000 out of pocket. These figures underscore why securing prior authorization or finding an alternative assistance program matters enormously before the patient begins therapy.

GoodRx and Discount Cards

GoodRx and similar discount cards can reduce the out-of-pocket cost at some pharmacies, but savings on specialty injectables are typically modest relative to the list price. Discount cards also cannot be combined with insurance coverage in most cases.

Eli Lilly Patient Assistance

Eli Lilly, the manufacturer of Forteo, operates the Lilly Cares Foundation. Patients who are uninsured or underinsured and meet income eligibility criteria (generally up to 400% of the federal poverty level) may receive Forteo at no or reduced cost. Prescribers can initiate enrollment through the Lilly Cares website or by calling 1-800-545-5979.

Bonsity: The Teriparatide Biosimilar

Radius Health received FDA approval for Bonsity (teriparatide injection, biosimilar) in June 2022 [7]. Bonsity carries the same 20 mcg/day dosing and the same 2-year lifetime cap. Because biosimilars are typically priced 15% to 30% below the reference product, Priority Health formularies for 2024 to 2025 may cover Bonsity at a lower tier than branded Forteo, making it worth asking the Priority Health pharmacy team whether a biosimilar substitution could lower the tier placement or cost-sharing.

Alternatives to Forteo That Priority Health Typically Covers at Lower Cost

If teriparatide coverage is denied or the patient is waiting for an appeal, the following agents are generally covered at lower tiers by Priority Health.

Bisphosphonates

Alendronate 70 mg weekly (generic, Tier 1 to 2 on most plans) and risedronate 35 mg weekly (generic, Tier 1 to 2) reduce vertebral fracture risk by roughly 40% to 50% in clinical trials [8]. They remain the standard first-line treatment for most patients with osteoporosis per National Osteoporosis Foundation and AACE guidelines [5][6].

Denosumab (Prolia)

Denosumab 60 mg subcutaneously every 6 months is approved for postmenopausal osteoporosis and is covered by most Priority Health plans, also with prior authorization. The FREEDOM trial (N=7,808) showed denosumab reduced new vertebral fracture risk by 68% and hip fracture risk by 40% over 36 months compared with placebo [9]. Denosumab is a reasonable option if bisphosphonates are contraindicated.

Romosozumab (Evenity)

Romosozumab 210 mg monthly subcutaneously for 12 months is another anabolic option approved for postmenopausal women with osteoporosis at high fracture risk. In the ARCH trial (N=4,093), romosozumab followed by alendronate reduced new vertebral fracture risk by 48% compared with alendronate alone over 24 months [10]. Priority Health coverage for romosozumab also requires prior authorization, and step therapy criteria are similar to those for teriparatide.

Key Clinical Evidence Supporting Teriparatide Use in High-Risk Patients

Insurance coverage decisions are ultimately grounded in clinical evidence and guideline designations. The evidence base for teriparatide in high-risk osteoporosis is substantial.

The Fracture Prevention Trial

The key registration trial enrolled 1,637 postmenopausal women with prior vertebral fractures and randomized them to teriparatide 20 mcg/day, teriparatide 40 mcg/day, or placebo. At a median of 18 months, the 20 mcg group showed a 65% relative risk reduction in new vertebral fractures (P<0.001) and a 53% reduction in non-vertebral fragility fractures (P<0.05) [3]. Lumbar spine BMD increased by 9.7% at 18 months compared with a 3.7% reduction in the placebo group.

AACE/ACE 2020 Clinical Practice Guidelines

The AACE/ACE 2020 guidelines on the management of osteoporosis state: "Anabolic therapies (teriparatide, abaloparatide, romosozumab) are recommended as first-line therapy for patients with very high fracture risk" [6]. Very high fracture risk is defined as a recent fracture (within 12 months), fracture on antiresorptive therapy, multiple fractures, or T-score below -3.0. Citing this language directly in a PA letter or appeal carries significant weight with Priority Health's clinical reviewers.

Glucocorticoid-Induced Osteoporosis Evidence

For patients on chronic glucocorticoid therapy, teriparatide outperforms bisphosphonates in head-to-head data. A 2007 trial (N=428) published in the New England Journal of Medicine found teriparatide increased lumbar spine BMD by 7.2% vs. 3.4% with alendronate at 18 months, and reduced new vertebral fractures significantly in glucocorticoid-using patients [11]. This is particularly relevant for Priority Health members on long-term prednisone who may meet step therapy exemption criteria.

Specific Numbers Prescribers Should Include in PA Letters

Concrete data points make a PA letter actionable. Rather than writing "the patient has severe osteoporosis," prescribers should write: "DXA dated [date] shows lumbar spine T-score -3.1, total hip T-score -2.7. FRAX 10-year probability of major osteoporotic fracture 28%, hip fracture probability 5.4%. Patient sustained a right distal radius fragility fracture in November 2024 while on alendronate 70 mg weekly for 14 months. Per AACE 2020 guidelines, this clinical profile meets the definition of very high fracture risk warranting first-line anabolic therapy."

According to the Endocrine Society's 2019 clinical practice guideline on osteoporosis in postmenopausal women: "We suggest using pharmacological therapy in postmenopausal women at high risk of fracture, defined as a BMD T-score of -2.5 or below at the lumbar spine or hip, or a T-score of -1.0 to -2.5 with a prior fragility fracture" [12]. Pairing this guideline language with the specific patient data leaves little clinical ambiguity for the reviewer.

Monitoring After Forteo Approval: What Priority Health May Require for Continuation

Most Priority Health PA approvals for teriparatide are granted for 6 to 12 months at a time with a renewal requirement. For renewal, prescribers typically need to document:

A follow-up DXA showing stable or improved BMD (typically ordered at 12 months of therapy), absence of hypercalcemia on a basic metabolic panel (teriparatide raises serum calcium in a small percentage of patients, usually transiently), and continued clinical indication consistent with the original PA approval. At the end of the 24-month cumulative lifetime limit, Priority Health will not renew the PA regardless of clinical response. Transitioning to an antiresorptive drug such as denosumab or a bisphosphonate after teriparatide is essential to preserve the BMD gains achieved. A 2018 study (N=94) showed that BMD gains from teriparatide were largely maintained at 24 months post-treatment in patients who transitioned immediately to alendronate, compared with significant losses in those who received no follow-on therapy [13].