Does Security Health Plan Cover Forteo?

What Is Forteo and Why Is It Prescribed?

Teriparatide, sold as Forteo by Eli Lilly, is a 34-amino-acid recombinant fragment of human parathyroid hormone. It works differently from bisphosphonates: instead of slowing bone breakdown, it actively stimulates new bone formation by acting on osteoblasts. The FDA approved Forteo in 2002 for postmenopausal women with osteoporosis at high fracture risk, men with primary or hypogonadal osteoporosis, and women and men with glucocorticoid-induced osteoporosis. [1]

Clinical Efficacy That Drives Prescribing

The key fracture prevention trial published in the New England Journal of Medicine (N=1,637 postmenopausal women with prior vertebral fractures) showed that teriparatide 20 mcg daily for a median of 19 months reduced new vertebral fracture risk by 65% compared with placebo (relative risk 0.35; 95% CI 0.22-0.55; P<0.001) and reduced non-vertebral fragility fractures by 53%. [2]

Lumbar spine bone mineral density increased by 9.7% in the teriparatide group versus 1.1% with placebo at 19 months. [2] Those numbers are the reason endocrinologists and rheumatologists reach for this drug when a patient has already fractured or has a T-score below -3.5.

FDA-Approved Indications Relevant to Coverage

Security Health Plan, like most commercial insurers, bases its medical necessity criteria directly on FDA-labeled indications. Forteo is covered for:

• Postmenopausal osteoporosis with high fracture risk
• Osteoporosis in men at high fracture risk
• Glucocorticoid-induced osteoporosis in men and women at high fracture risk who are taking systemic glucocorticoids equivalent to 5 mg/day or more of prednisone for at least 3 months

Off-label uses (such as fracture healing acceleration) are generally not covered. [3]

How Security Health Plan's Formulary Works

Security Health Plan is a Wisconsin-based HMO with both commercial and Medicare Advantage products. Its formularies are published annually and can change each plan year, so the information below reflects general patterns reported in 2024-2025 plan documents.

Formulary Tier Placement

Forteo is placed on the Specialty tier of Security Health Plan's formularies. Specialty tiers carry the highest cost-sharing, typically structured as a percentage of the drug's cost (coinsurance) rather than a flat copay. On commercial plans, member coinsurance for specialty drugs often runs 20-30% of cost, which translates to $620-$1,020 per 28-day pen at list price.

Medicare Advantage formularies follow CMS rules. The 2025 Medicare Part D redesign capped out-of-pocket drug spending at $2,000 per year per beneficiary, which meaningfully changes the math for Forteo users in those plans. [4]

Prior Authorization Requirements

Prior authorization (PA) is required on every Security Health Plan product that lists Forteo. The PA criteria used by most Wisconsin commercial insurers, including Security Health Plan, align with guidance from the Endocrine Society and the American Association of Clinical Endocrinologists. A PA submission typically must document:

1. A confirmed diagnosis of osteoporosis via DXA with T-score at or below -2.5, or a clinical fragility fracture with documented low bone mass
2. High fracture risk classification (FRAX 10-year major osteoporotic fracture probability at or above 20%, or hip fracture probability at or above 3%, per the 2020 American College of Rheumatology glucocorticoid-induced osteoporosis guidelines) [5]
3. Documentation of step therapy completion (see below) or a valid exception reason
4. Prescriber attestation that the 2-year lifetime limit is understood and that the patient can self-inject

PA approvals are typically valid for 12 months, with renewal requiring documentation of bone density response or persistent fracture risk.

Step Therapy: The Bisphosphonate-First Requirement

Step therapy is the rule, not the exception, for anabolic osteoporosis agents on Security Health Plan. Before Forteo will be approved, the plan generally requires:

• At least one trial of an oral bisphosphonate (alendronate or risedronate, typically for 3-6 months) unless the prescriber documents a contraindication or intolerance
• Documentation of the reason bisphosphonate therapy failed or was not tolerated (esophageal disease, inability to remain upright 30 minutes, renal insufficiency with creatinine clearance <35 mL/min, or persistent GI adverse effects)

Alendronate 70 mg once weekly is available as a generic for under $15 per month, which is the cost-offset rationale insurers use for step therapy. [6] If a patient has already tried and failed bisphosphonate therapy, that documentation should be gathered before submitting the PA.

Prior Authorization: A Step-by-Step Submission Guide

Getting a PA approved requires attention to documentation detail. Missing one piece of clinical evidence is the most common reason initial requests are denied.

Step 1: Gather Required Clinical Documents

Collect the following before submitting:

• DXA report with T-scores at lumbar spine and femoral neck (scan dated within 24 months)
• FRAX calculation printout (available free at sheffield.ac.uk/FRAX)
• Fracture history: radiology reports confirming any fragility fractures
• Bisphosphonate trial records or contraindication documentation
• Current medication list (especially glucocorticoids, if applicable)
• Prescriber's office notes confirming the diagnosis and rationale for anabolic therapy

Step 2: Complete the PA Form Correctly

Security Health Plan accepts PA requests through its provider portal, by fax, or through electronic prior authorization (ePA) systems. The treating physician or an authorized staff member submits the request. Make sure the diagnosis code is specific: M80.00XA or similar ICD-10 code for age-related osteoporosis with current fragility fracture carries more weight than a general osteoporosis code.

Step 3: Timeframes and Urgency

Standard PA decisions are required within 3 business days under Wisconsin insurance regulations and federal rules. Urgent requests (when a standard delay could seriously harm the patient) must be decided within 24 hours. [7]

Step 4: What Triggers an Automatic Denial

Common automatic denial triggers include:

• No documented DXA on file
• FRAX score not meeting threshold (below 20% major osteoporotic or below 3% hip)
• Bisphosphonate step therapy not completed and no documented exception
• Requests for more than the FDA-approved 24-month cumulative lifetime dose
• Diagnosis codes that suggest off-label use

What Forteo Actually Costs With and Without Coverage

With Security Health Plan Coverage

If the PA is approved, the member pays the specialty tier cost-sharing amount. For a commercial plan with 25% coinsurance on specialty drugs and a list price of $3,200 per pen:

• Member coinsurance per month: approximately $800 before the deductible is met, dropping to approximately $800 per month until the out-of-pocket maximum is reached, then $0

Deductibles on commercial Security Health Plan products vary by employer group. Integrated deductibles that apply to both medical and pharmacy can delay when cost-sharing kicks in.

Without Coverage or During a Gap

The average wholesale price for one Forteo prefilled pen (28-day supply) ran approximately $3,300 as of late 2024. Cash prices through discount programs like GoodRx vary by pharmacy but rarely fall below $2,800 in Wisconsin without manufacturer assistance.

Eli Lilly Patient Support Programs

Eli Lilly operates the Lilly Cares Foundation patient assistance program, which may provide Forteo at no cost to patients who meet income criteria (generally household income at or below 400% of the federal poverty level with no third-party coverage). [8] Lilly also offers a commercial co-pay card that can reduce out-of-pocket costs to as low as $15 per month for eligible commercially insured patients. Medicare and Medicaid beneficiaries are generally not eligible for commercial co-pay cards.

What to Do If Your Claim Is Denied

A denial is not the end. Federal and Wisconsin state law provide structured appeal rights.

Internal Appeal

Members have the right to request an internal appeal within 180 days of receiving a denial notice under ACA rules. [7] The insurer must review the appeal and provide a decision within 30 days for prospective requests or 60 days for post-service claims. Submit:

• A letter of medical necessity from the prescribing physician, citing specific clinical findings
• The DXA report and FRAX output
• Peer-reviewed references supporting anabolic therapy in your patient's clinical profile (the 2022 Endocrine Society Clinical Practice Guideline on Pharmacological Management of Osteoporosis is a strong citation to include) [9]
• Documentation of bisphosphonate failure or intolerance

External Appeal

If the internal appeal is denied, Wisconsin law allows members to request an independent external review. The external reviewer is a board-certified physician not affiliated with the insurer. For osteoporosis drugs, external reviewers routinely apply clinical guidelines, and approvals at this stage are not uncommon when the clinical documentation is thorough.

Peer-to-Peer Review

Before or during the internal appeal, the prescribing physician can request a peer-to-peer phone call with the insurer's medical director. This is often the fastest path to reversal. Physicians should prepare specific clinical arguments, citing fracture history, T-score severity, and why anabolic therapy is superior to antiresorptive therapy in this particular patient.

Forteo vs. Other Anabolic Agents: Coverage Implications

Forteo is not the only anabolic option. Understanding the alternatives helps patients and prescribers manage coverage barriers.

Abaloparatide (Tymlos)

Abaloparatide (Tymlos, Radius Health) is a parathyroid hormone-related protein analog approved in 2017. The ACTIVE trial (N=2,463) showed an 86% reduction in new vertebral fractures versus placebo over 18 months (P<0.001), with a 43% reduction in non-vertebral fractures versus placebo. [10] Security Health Plan's specialty tier typically includes Tymlos on similar PA criteria as Forteo. Some plans have preferred one over the other in a given year, so checking the current formulary year's document is always the right first move.

Romosozumab (Evenity)

Romosozumab (Evenity, Amgen/UCB) is a sclerostin inhibitor that both stimulates bone formation and reduces bone resorption. It is given as two subcutaneous injections once monthly for 12 months. The ARCH trial (N=4,093 postmenopausal women with osteoporosis and a prior fragility fracture) showed romosozumab followed by alendronate reduced new vertebral fracture risk by 48% compared with alendronate alone (P<0.001). [11] Evenity carries an FDA boxed warning for major adverse cardiovascular events (MACE) and is generally contraindicated within 12 months of a myocardial infarction or stroke. Coverage criteria on Security Health Plan typically mirror the FDA label restrictions.

Biosimilar Teriparatide: Bonsity

Bonsity (TransCon PTH from Ascendis / generic teriparatide from Alvogen/Teva) is an FDA-approved biosimilar to Forteo. Security Health Plan may list Bonsity as a preferred alternative to Forteo on the specialty tier, meaning the PA criteria are the same but the tier copay or coinsurance might be lower. Patients and prescribers should check the current year formulary to see which product is preferred. [12]

Osteoporosis Diagnosis Standards That Support a PA

Understanding what clinical thresholds justify Forteo helps prescribers write stronger PA requests and helps patients advocate for themselves.

T-Score Thresholds

The World Health Organization defines osteoporosis as a DXA T-score at or below -2.5 at the lumbar spine, femoral neck, or total hip. [13] A T-score between -1.0 and -2.5 is osteopenia, which generally does not qualify for Forteo unless there is also a fragility fracture.

FRAX Thresholds for U.S. Treatment Initiation

The National Osteoporosis Foundation (now merged with the American Bone Health organization) and the AACE both recommend pharmacologic treatment when:

• The 10-year FRAX probability of a major osteoporotic fracture reaches 20% or above, or
• The 10-year FRAX probability of hip fracture reaches 3% or above [14]

A prior low-trauma fracture after age 50 independently qualifies most patients for pharmacologic treatment without needing a FRAX calculation.

Glucocorticoid-Induced Osteoporosis: Lower Threshold

For patients taking 5 mg/day or more of prednisone (or equivalent) for 3 months or longer, the 2022 ACR guideline lowers the FRAX threshold for initiating treatment. High-dose glucocorticoids (at or above 30 mg/day prednisone for at least one month) independently confer high fracture risk. [5] Forteo is FDA-approved for this indication, and prescribers should document glucocorticoid dose, duration, and the modified FRAX risk category explicitly in the PA.

Post-Treatment Planning: What Happens After 24 Months

Forteo's FDA-approved lifetime limit is 24 months. This limit is enforced by Security Health Plan's PA renewal process, and no additional teriparatide will be authorized beyond that cumulative duration.

After completing Forteo, the bone density gains must be preserved with antiresorptive therapy. The 2022 Endocrine Society guideline states: "After completing a course of anabolic therapy, anti-resorptive therapy is recommended to maintain gains in bone mineral density." [9] Without follow-on antiresorptive therapy, BMD gains from teriparatide can be lost within 12-18 months. Alendronate or zoledronic acid (a once-yearly intravenous bisphosphonate) are the most studied sequential regimens.

Security Health Plan covers zoledronic acid (Reclast) under the medical benefit as an outpatient infusion, typically at a lower tier cost than specialty oral or injectable drugs. Prescribers should plan the sequential therapy conversation before month 18 of teriparatide treatment.

Practical Tips for Patients

Getting Forteo covered is a documentation exercise as much as a clinical one. A few steps that improve the odds:

• Ask the prescriber's office to use the insurer's specialty pharmacy. Security Health Plan often requires specialty drugs to be dispensed through a contracted specialty pharmacy (such as Accredo or a plan-owned pharmacy). Using an out-of-network pharmacy may result in a denial that looks like a formulary denial but is actually a network issue.
• Confirm the formulary year every October during open enrollment. Tier placement and PA criteria can change annually.
• Apply for Lilly Cares or the commercial co-pay card before the first fill so there is no gap in assistance.
• Keep all DXA reports and fracture X-rays in a personal medical file. Appeals require rapid document submission.
• Request a prior authorization start date that aligns with the start of a new plan year if you are approaching your deductible reset.