Does Quartz Health Solutions Cover Forteo?

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

Forteo is a recombinant form of human parathyroid hormone (1-34), delivered by daily self-injection, 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, and the label was broadened in later years to include men with primary or hypogonadal osteoporosis and patients with glucocorticoid-induced osteoporosis. [1]

Because the monthly list price sits around $3,200, nearly every commercial and Medicare Advantage insurer, including Quartz Health Solutions, classifies Forteo as a specialty-tier drug requiring prior authorization before dispensing.

Why Quartz Uses Prior Authorization for Specialty Drugs

Prior authorization is a utilization-management tool insurers use to confirm medical necessity before covering high-cost agents. Quartz's pharmacy and therapeutics committee reviews specialty drugs annually and sets criteria based on FDA-approved indications, published guidelines, and comparative-effectiveness data. For anabolic osteoporosis agents such as Forteo, Quartz's criteria typically align with criteria from the American Association of Clinical Endocrinologists and the Endocrine Society, both of which reserve anabolic therapy for patients with severe or very high fracture risk. [2]

The Clinical Rationale That Drives Coverage Criteria

The Endocrine Society's 2019 clinical practice guideline on osteoporosis states: "We recommend anabolic agents for patients with very high fracture risk, defined as a recent fracture within the past 12 months, very low BMD (T-score <-3.0), or prior fracture while on antiresorptive therapy." [2] Quartz's medical policies echo this threshold language almost verbatim, which means your prescriber's documentation must hit these specific markers to succeed on prior authorization.

How to Confirm Your Quartz Plan's Formulary Status for Forteo

Formulary placement differs by plan type. Quartz offers commercial employer-sponsored plans, individual marketplace plans, and Medicare Advantage plans, each with its own formulary document.

Steps to Check Formulary Coverage

1. Log in to your Quartz member portal at quartz.com and manage to "Find a Drug."
2. Search for "teriparatide" or "Forteo" and select your plan year.
3. Note the tier number, any quantity limits (Quartz commonly limits to a 30-day supply per fill for specialty injectables), and whether a prior authorization icon appears.
4. Download the Summary of Benefits and Coverage or call the member services number on the back of your insurance card to confirm specialty pharmacy requirements.

Quartz partners with specific specialty pharmacy networks. Dispensing Forteo through an out-of-network specialty pharmacy could result in higher cost-sharing or outright denial, so confirming the in-network specialty pharmacy is a necessary first step before your prescriber submits any authorization request.

Plan-Type Differences

Commercial plans through an employer may cover Forteo with a specialty copay ranging from $100 to $400 per month after deductible, depending on how the plan was designed. Individual marketplace plans sold through the ACA exchange tend to have higher cost-sharing at the specialty tier. Medicare Advantage plans administered by Quartz must follow CMS formulary rules, and teriparatide is typically on a specialty tier with a 25% to 33% coinsurance structure during the initial coverage phase, which translates to roughly $800 to $1,000 per month for many beneficiaries before reaching catastrophic coverage. [3]

Prior Authorization Requirements: What Quartz Typically Demands

Prior authorization for Forteo through Quartz is not a rubber-stamp process. The review team looks for a constellation of clinical findings, and a submission missing any one element is commonly the reason for an initial denial.

Standard Clinical Criteria

Most Quartz medical policies for anabolic bone agents require all of the following:

• A confirmed diagnosis of osteoporosis, documented by dual-energy X-ray absorptiometry (DXA) showing a T-score of <-2.5 at the spine, total hip, or femoral neck, or a fragility fracture history regardless of T-score.
• Evidence of high or very high fracture risk. The FRAX tool, developed and validated by the WHO Collaborating Centre for Metabolic Bone Diseases, provides a 10-year probability calculation that clinicians can use to support this determination. [4]
• Documentation that the patient has either failed or is intolerant of a bisphosphonate. Commonly accepted first-line agents include alendronate (Fosamax), risedronate (Actonel), and zoledronic acid (Reclast). "Failure" is generally defined as a new fracture or continued BMD decline despite at least 12 months of adherent therapy.
• Prescriber attestation from an appropriate specialist (endocrinologist, rheumatologist, or primary care physician with documented osteoporosis experience).

Contraindications That Can Bypass Step Therapy

Bisphosphonate step therapy is not always required. Quartz's criteria include exemptions for patients who have a contraindication to bisphosphonates, such as renal insufficiency with an estimated GFR <35 mL/min/1.73m², severe esophageal disease, or a documented bisphosphonate hypersensitivity reaction. Patients with Paget's disease, prior radiation therapy involving the skeleton, or elevated alkaline phosphatase of unexplained origin may also qualify for direct anabolic therapy because teriparatide carries an FDA black-box warning in those populations, which itself shapes prescribing practice. [1]

Black Box Warning and Its Effect on Coverage Decisions

The Forteo prescribing label carries a black-box warning for osteosarcoma risk based on rat studies showing dose- and duration-dependent tumors at exposures far exceeding human doses. [1] Although the clinical relevance in humans remains uncertain and no causal link has been established in postmarketing surveillance, Quartz (like most payers) uses this warning to justify quantity limits and a 24-month lifetime maximum on teriparatide use. The FDA itself updated the label in 2020 to remove the boxed warning requirement for the Risk Evaluation and Mitigation Strategy (REMS) program after postmarketing data did not confirm elevated human osteosarcoma risk. [1] Your prescriber can reference this 2020 label change when responding to any insurer concern about duration of therapy.

The Prior Authorization Appeal Process If Quartz Denies Coverage

An initial denial is not a final answer. Federal law under the ACA and CMS regulations gives you specific rights to appeal, and many denials are overturned when the clinical record is submitted completely.

First-Level Internal Appeal

Within 30 days of receiving a denial notice (or 72 hours for an urgent/expedited appeal), submit a first-level internal appeal to Quartz. The appeal should include:

• A letter of medical necessity from your prescriber that references your T-score, FRAX score, fracture history, and prior treatment record.
• Copies of DXA reports showing BMD values.
• Pharmacy dispensing records or prescriber attestation documenting bisphosphonate use or documented intolerance.
• Any peer-reviewed literature supporting anabolic therapy in your clinical scenario.

The NEJM published the landmark Fracture Prevention Trial (FPT) showing that teriparatide 20 mcg/day reduced vertebral fracture risk by 65% (relative risk 0.35, 95% CI 0.22 to 0.55, P<0.001) and nonvertebral fracture risk by 53% compared with placebo in postmenopausal women with prior vertebral fractures. [5] Including this citation in your appeal letter gives Quartz's medical reviewer a direct, high-quality reference for efficacy.

External Independent Review

If Quartz upholds the denial at first-level internal appeal, you have the right to request an external independent review by a state-certified independent review organization. In Wisconsin, where Quartz is headquartered and holds most of its membership, the Office of the Commissioner of Insurance oversees the external review process. External reviewers are not employed by Quartz and apply objective clinical standards. Published data suggest roughly 40% to 60% of external reviews result in overturning insurer denials for specialty drugs, though exact figures vary by drug class and state. [6]

Cost and Financial Assistance Options

Even with coverage, the out-of-pocket burden for a specialty injectable like Forteo can be significant.

Lilly Cares Foundation Patient Assistance

Eli Lilly offers the Lilly Cares Foundation program for patients who meet income criteria (generally at or below 400% of the federal poverty level) and who are uninsured or underinsured. Eligible patients may receive Forteo at no cost. Applications are submitted through lillycares.com and require income documentation and a prescriber signature.

Forteo Savings Card for Commercially Insured Patients

For commercially insured patients who do not qualify for the foundation program, Eli Lilly has offered a savings card that reduces monthly out-of-pocket costs to as low as $25 per fill. This program does not apply to patients with Medicare, Medicaid, or other federal insurance programs due to anti-kickback regulations. [7]

Biosimilar and Alternative Anabolic Agents

Teriparatide biosimilar Bonsity (Alvogen) received FDA approval and launched in the U.S. Market at a lower list price than Forteo. If Quartz's formulary includes Bonsity at a lower tier than Forteo, switching to the biosimilar may reduce your cost-sharing substantially while delivering the same clinical effect, since biosimilars are required by the FDA to demonstrate no clinically meaningful differences from the reference product. [8]

Abaloparatide (Tymlos, Radius Health) is a related parathyroid hormone-related protein analog approved by the FDA in 2017 for postmenopausal osteoporosis at high fracture risk. [9] In the ACTIVE trial (N=2,463), abaloparatide reduced new vertebral fractures by 86% relative to placebo at 18 months. [9] Some Quartz plans place Tymlos at a different formulary tier than Forteo, so asking your prescriber whether abaloparatide is a clinically appropriate alternative could open a less expensive covered option.

What Your Prescriber Can Do to Maximize Approval Chances

The single strongest predictor of prior authorization success is the completeness of the initial submission. Insurers deny incomplete submissions far more often than they deny well-documented ones.

Documentation Checklist for Prescribers

Prescribers submitting Forteo prior authorizations to Quartz should confirm the following before clicking submit:

1. DXA report with numeric T-scores at spine and hip, dated within the past 24 months.
2. FRAX score with BMD input, printed from the WHO FRAX tool, dated within the past 12 months. [4]
3. ICD-10-CM diagnosis code: M81.0 (age-related osteoporosis without current pathological fracture) or M80.00XA through M80.08XA series for osteoporosis with current pathological fracture.
4. Prior treatment history: drug name, dose, start date, end date, and reason for discontinuation or documented failure.
5. Relevant comorbidities that affect drug selection (renal function panel if GFR is borderline, esophageal motility study if relevant).
6. Prescriber's NPI number and specialty.
7. Preferred specialty pharmacy name and phone number.

Submitting all seven items in the first request reduces back-and-forth requests for additional information, which is the most common cause of authorization delays.

Peer-to-Peer Review Request

If the authorization is denied on initial review by a non-physician reviewer, your prescriber can request a peer-to-peer call with Quartz's medical director. During this call, the prescriber speaks directly with a physician reviewer and can present the clinical rationale in real time. Many physicians report that peer-to-peer reviews resolve denials more efficiently than written appeals for complex specialty drug cases.

Clinical Evidence Supporting Teriparatide Use in High-Risk Patients

Understanding the evidence base behind Forteo helps both patients and prescribers communicate with insurers about why this drug is medically necessary in specific populations.

Vertebral and Nonvertebral Fracture Reduction

The Fracture Prevention Trial, published in the NEJM in 2001 (N=1,637 postmenopausal women with prior vertebral fractures), remains the key registration study for Forteo. Teriparatide 20 mcg/day reduced new vertebral fractures by 65% and nonvertebral fractures by 53% over a median 21-month treatment period compared with placebo. [5] These effect sizes are larger than those reported for oral bisphosphonates in comparable trial populations.

BMD Gains Versus Antiresorptive Agents

A 2016 head-to-head trial published in the NEJM (VERO trial, N=680) compared teriparatide with risedronate in postmenopausal women with severe osteoporosis and prior vertebral fractures. Teriparatide reduced new clinical vertebral fractures by 56% relative to risedronate (RR 0.44, 95% CI 0.29 to 0.68, P<0.001) and produced greater BMD gains at the lumbar spine (7.0% vs. 3.5% at 24 months). [10] This trial is particularly useful for insurers asking why bisphosphonate continuation is not sufficient for a given patient.

Glucocorticoid-Induced Osteoporosis

Patients receiving chronic glucocorticoid therapy (prednisone equivalent >5 mg/day for more than 3 months) face accelerated bone loss through suppression of osteoblast activity. A randomized trial (N=428) published in NEJM in 2007 found teriparatide increased spine BMD by 7.2% versus a 0.7% gain with alendronate at 18 months in patients on long-term glucocorticoids. [11] The American College of Rheumatology 2022 guidelines on glucocorticoid-induced osteoporosis now recommend anabolic therapy as first-line treatment for very high-risk patients in this population, which may further support prior authorization requests for Quartz members on chronic steroids. [12]

After Forteo: Transition Therapy and Long-Term Planning

Teriparatide is approved for a maximum of 24 months of use (lifetime total, not per course). Stopping Forteo without transitioning to an antiresorptive agent results in rapid bone loss, reversing a substantial portion of the BMD gains achieved during treatment.

Sequential Therapy Protocol

Clinical guidelines from the Endocrine Society and the American Society for Bone and Mineral Research recommend starting an antiresorptive agent, typically a bisphosphonate or denosumab (Prolia), within a few months of completing teriparatide therapy. [2] The transition ensures that the new bone formed during anabolic therapy is consolidated rather than lost. Quartz coverage for the subsequent antiresorptive agent generally follows standard formulary rules, and bisphosphonates such as generic alendronate are available for as little as $10 to $15 per month at most pharmacies.

Romosozumab as an Alternative Anabolic Agent

Romosozumab (Evenity, Amgen/UCB) is a sclerostin inhibitor with dual anabolic and antiresorptive effects, approved by the FDA in 2019 for postmenopausal women with osteoporosis at very high fracture risk. [13] Quartz coverage for romosozumab follows a similar prior authorization pathway as teriparatide. The ARCH trial (N=4,093) showed romosozumab followed by alendronate reduced vertebral fractures by 48% and hip fractures by 38% compared with alendronate alone over 24 months. [13] For patients who cannot use teriparatide due to prior radiation or Paget's disease (listed contraindications), romosozumab is a covered anabolic alternative to discuss with your prescriber.