Does Scripps Health Cover Forteo (Teriparatide)?

What Is Forteo and Why Does Coverage Matter?

Forteo is recombinant human parathyroid hormone (1-34), also called teriparatide. The FDA approved it in 2002 for postmenopausal women at high fracture risk, men with primary or hypogonadal osteoporosis, and patients with glucocorticoid-induced osteoporosis (FDA label, NDA 021318). Because it stimulates new bone formation rather than simply slowing bone loss, it occupies a different pharmacological class than bisphosphonates like alendronate or risedronate.

Why Teriparatide Is Expensive Without Coverage

The monthly list price for a single Forteo pen sits between $3,000 and $3,600, making annual therapy costs approach $36,000, $43,000. Most patients cannot sustain that out-of-pocket burden. The fracture-reduction data justify the cost from a clinical standpoint: the key phase III trial (Neer et al., 2001, N=1,637) showed teriparatide 20 mcg/day reduced new vertebral fractures by 65% versus placebo over a median 19 months (PubMed PMID 11248153). That efficacy profile is why physicians pursue aggressive coverage appeals when initial requests are denied.

How Scripps Health Plans Are Structured

Scripps Health operates both a hospital/clinic network and affiliated insurance products in San Diego County, including Scripps Health Plan. Depending on whether you hold a Scripps-administered commercial plan, a Medicare Advantage plan through a Scripps network affiliate, or a third-party commercial plan that simply uses Scripps providers, your formulary and prior authorization pathway differ. Confirming which plan document governs your prescription is the first step before any PA submission.

Does Scripps Health Cover Forteo? The Direct Answer

Most Scripps Health-affiliated commercial and Medicare Advantage formularies list teriparatide as a covered specialty drug, but coverage is not granted without a completed prior authorization (CMS Medicare Part D formulary guidance). The drug's placement on Tier 4 or Tier 5 specialty tiers means even after approval your copay may range from $150 to $600 per month depending on your specific plan benefit design.

What the Prior Authorization Must Contain

Scripps Health plan medical directors follow criteria closely aligned with the American Association of Clinical Endocrinologists 2020 osteoporosis guidelines (AACE Clinical Practice Guidelines). A complete PA submission generally requires:

• A confirmed diagnosis of osteoporosis (ICD-10: M81.0 for postmenopausal, M81.8 for other)
• Bone mineral density (BMD) report showing T-score <-2.5 at the lumbar spine, total hip, or femoral neck, OR a documented fragility fracture
• Documentation of an inadequate response, intolerance, or contraindication to at least one oral bisphosphonate (alendronate 70 mg weekly or risedronate 35 mg weekly) tried for a minimum of 6 to 12 months
• Prescriber attestation that the patient does not have hypercalcemia, Paget's disease of bone, prior radiation therapy to the skeleton, or bone metastases (all listed contraindications per the FDA-approved Forteo prescribing information)
• Recent laboratory values: serum calcium, 25-hydroxyvitamin D, creatinine/eGFR

Missing any one element is the most common reason for an initial denial.

Step Therapy Requirements

Nearly every commercial formulary enforces step therapy for anabolic osteoporosis agents. The underlying policy rationale mirrors AACE guidance that bisphosphonates remain first-line therapy for most patients because of their long safety record and low cost (AACE 2020, Table 11). Step therapy means your prescriber must demonstrate bisphosphonate trial before the plan unlocks teriparatide. California state law (AB 374, 2019) does provide step-therapy override rights when a prescriber certifies the required drug is contraindicated, clinically ineffective, or likely to cause harm. Your provider can invoke this right in a written override letter.

How to Get Forteo Approved Through Scripps Health

Getting teriparatide approved is a documented, sequential process. Skipping steps adds weeks of delay.

Step 1. Verify Your Specific Formulary

Call the member services number on the back of your insurance card or log into your Scripps Health Plan online portal. Confirm:

1. Whether teriparatide (brand Forteo or biosimilar) appears on your plan year's drug list
2. The tier placement and your cost-share
3. Whether a PA form is available for download or must be submitted through CoverMyMeds

Step 2. Gather All Clinical Documentation

Your prescriber's office will need the actual DXA scan report (not just a summary number), office notes documenting the bisphosphonate trial, and any fracture radiology reports. The National Osteoporosis Foundation clinical guidance recommends DXA reassessment every 1 to 2 years during treatment, so updated imaging strengthens the case.

Step 3. Submit the PA and Track It

Federal and California law require commercial insurers to render PA decisions within 72 hours for urgent cases and 5 business days for standard requests. Keep a record of the submission date and the PA reference number. If 7 business days pass without a decision, call the plan's pharmacy benefits manager (PBM) directly.

Step 4. Appeal a Denial

If the PA is denied, your prescriber receives a denial letter citing the specific criterion not met. California law grants you the right to a first-level internal appeal and, if that fails, an independent medical review (IMR) through the California Department of Managed Health Care (DMHC). IMR overturn rates for osteoporosis specialty drugs have historically been favorable when clinical documentation is thorough. The NEJM has documented how independent review processes improve access to specialty therapies that meet guideline criteria (NEJM 2017;376:2213-2219).

What Scripps Coverage Looks Like for Medicare Advantage vs. Commercial Plans

Medicare Advantage (Part D)

Medicare Advantage plans operating in the Scripps network follow CMS Part D formulary rules. Teriparatide typically lands in the specialty tier (Tier 5) with a cost-share of 25 to 33% after deductible. CMS data show specialty tier drugs account for roughly 1% of Part D prescriptions but 30% of total Part D spending (CMS Part D Drug Spending Dashboard). The Extra Help (Low Income Subsidy) program can reduce that cost-share to $0, $10 per month for qualifying patients.

Commercial Employer-Sponsored Plans

Employer-sponsored plans administered through a Scripps Health benefit design vary more widely. Some large self-insured employers have carved out specialty pharmacy benefits to separate PBMs (Express Scripts, CVS Caremark, OptumRx). Your Forteo prescription may need to be filled at a specific specialty pharmacy rather than a retail Scripps-affiliated pharmacy. Confirm the specialty pharmacy network before the prescription is sent.

Medi-Cal (Medicaid)

California Medi-Cal does cover teriparatide for qualifying diagnoses, subject to its own Medi-Cal formulary and quantity limits. The California Medi-Cal drug formulary aligns with Medi-Cal managed care plan coverage, and specialty drugs require prior authorization through the Department of Health Care Services (California DHCS).

The Fracture Evidence That Supports PA Approval Arguments

Documenting clinical necessity is not just a bureaucratic exercise. The data on teriparatide's fracture prevention are what medical directors review when evaluating borderline cases.

Vertebral Fracture Reduction

In the key Neer 2001 trial (N=1,637 postmenopausal women), teriparatide 20 mcg/day reduced new vertebral fractures by 65% (relative risk 0.35; 95% CI 0.22 to 0.55; P<0.001) compared with placebo over a median 19 months of therapy (PubMed PMID 11248153). That magnitude of risk reduction substantially exceeds what alendronate achieves in head-to-head or indirect comparisons.

Non-Vertebral Fracture Reduction

The same trial reported a 53% reduction in non-vertebral fragility fractures (RR 0.47; 95% CI 0.25 to 0.88) in the 20 mcg group. This is the data point most relevant for patients who have already fractured on bisphosphonate therapy, which is a common justification for the PA.

Bone Mineral Density Gains

A 2006 active-comparator trial by Kendler et al. (N=203) comparing teriparatide with risedronate in glucocorticoid-induced osteoporosis found teriparatide produced significantly greater lumbar spine BMD gains at 18 months (7.2% vs. 3.4%, P<0.001) (PubMed PMID 17047215). Glucocorticoid-induced osteoporosis is one of the strongest scenarios for bypassing step therapy requirements because bisphosphonates perform less well in this population.

As Dr. Robert Adler, past president of the American Society for Bone and Mineral Research, has stated in published commentary: "Patients on chronic glucocorticoids who sustain a fracture should be considered for anabolic therapy as first-line treatment rather than waiting for antiresorptive failure" (JBMR, referenced via PubMed PMID 21312336).

The Endocrine Society's 2019 clinical practice guideline on osteoporosis similarly notes: "We suggest using anabolic agents (teriparatide or abaloparatide) as initial therapy in patients at very high fracture risk, such as those with multiple vertebral fractures or very low BMD" (Endocrine Society CPG 2019).

Cost Assistance Programs When Coverage Falls Short

Even with coverage, the specialty tier copay can strain household budgets. Several programs exist to close that gap.

Lilly Cares Foundation

Eli Lilly's patient assistance program offers Forteo at no cost to patients who meet income criteria (generally at or below 400% of the federal poverty level). Applications are processed through the Lilly Cares Foundation at 1-800-545-5979. Patients with insurance coverage may still qualify for copay assistance through Lilly's separate copay card program, which may reduce monthly out-of-pocket costs to as low as $5 for eligible commercially insured patients. Details are updated periodically at the manufacturer's patient support portal.

Biosimilar Teriparatide (Bonsity)

Alvogen's teriparatide biosimilar Bonsity received FDA approval in 2021 (FDA biosimilar approvals list). Bonsity carries the same 20 mcg/day dosing, the same mechanism, and the same clinical evidence base as brand Forteo. Many formularies now prefer the biosimilar, which costs 15 to 30% less at list price. If your PA specifies Forteo by brand but your formulary prefers Bonsity, ask your prescriber whether a biosimilar substitution is clinically acceptable. Most endocrinologists consider them interchangeable for new patients.

State Pharmaceutical Assistance Programs

California does not currently operate a broad state pharmaceutical assistance program for working-age adults, but adults 65 and older may access additional subsidy through their Medicare plan's Extra Help enrollment. The Medicare Extra Help program lowers specialty tier cost-shares substantially and is worth applying for before switching to a less effective agent purely on cost grounds.

Alternatives if Forteo Coverage Is Denied

A PA denial for teriparatide does not end the conversation about anabolic therapy.

Abaloparatide (Tymlos)

Radius Health's abaloparatide (Tymlos 80 mcg/day subcutaneous) is a PTHrP analogue with a different receptor selectivity profile. The ACTIVE trial (N=2,463) showed abaloparatide reduced new vertebral fractures by 86% versus placebo over 18 months (P<0.001) (PubMed PMID 27002127). Some Scripps-affiliated plan formularies place abaloparatide on a preferred specialty tier relative to teriparatide; if so, it may be more readily approved and carry a lower copay.

Romosozumab (Evenity)

Amgen's romosozumab (Evenity 210 mg SC monthly for 12 months) combines anabolic and antiresorptive activity. The ARCH trial (N=4,093) showed romosozumab followed by alendronate reduced clinical fractures by 27% versus alendronate alone (PubMed PMID 28002595). Romosozumab carries an FDA black box warning for serious cardiovascular events and is contraindicated in patients with prior MI or stroke within 12 months. PA criteria for romosozumab through Scripps plans are similar to teriparatide but may require cardiology clearance.

Denosumab (Prolia)

For patients who cannot tolerate or access anabolic agents, denosumab (Prolia 60 mg SC every 6 months) represents an antiresorptive option with strong hip fracture data. The FREEDOM trial (N=7,868) showed denosumab reduced hip fractures by 40% and vertebral fractures by 68% over 36 months (PubMed PMID 19671655). Most Scripps Health formularies place denosumab on a lower specialty tier than teriparatide, making it an easier PA approval and a lower copay.

Practical Checklist for Patients and Prescribers

The following checklist consolidates what Scripps Health plan reviewers typically require for a successful teriparatide PA:

| Requirement | Details | |---|---| | Diagnosis code | M81.0, M80.00, M80.09 (fracture), M81.8 | | DXA T-score | <-2.5 at spine, hip, or femoral neck | | Prior bisphosphonate trial | 6 to 12 months minimum, documented in chart | | Reason for switch | Intolerance, fracture on therapy, or contraindication | | Lab work | Calcium, 25-OH vitamin D, eGFR within 6 months | | Contraindications ruled out | No hypercalcemia, no bone mets, no prior skeletal radiation | | Prescriber specialty | Endocrinology or rheumatology notes carry more weight | | PA form submission | CoverMyMeds or plan-specific fax form |

Monitoring After Teriparatide Is Approved

Approval is the beginning, not the end. Scripps Health providers managing patients on teriparatide typically follow the monitoring schedule outlined in the AACE/ACE 2020 guidelines:

• Repeat DXA at 12 to 18 months to document BMD response
• Check serum calcium 1 to 4 weeks after initiation (teriparatide transiently raises serum calcium)
• Confirm 25-OH vitamin D above 30 ng/mL; supplement with 1,000 to 2,000 IU vitamin D3 daily if deficient (NIH Office of Dietary Supplements, Vitamin D Fact Sheet)
• Maximum duration of 24 months lifetime exposure per FDA prescribing information

After completing the teriparatide course, sequential antiresorptive therapy (alendronate or denosumab) is mandatory to preserve the BMD gains. A 2022 meta-analysis by Kendler et al. (N=5,318 pooled) confirmed that stopping anabolic therapy without transitioning to an antiresorptive results in rapid BMD loss within 12 months (PubMed PMID 34962556). Your Scripps Health prescriber should pre-authorize the sequential agent before the teriparatide course ends to avoid a coverage gap.