Does Blue Cross Blue Shield of Arizona Cover Forteo?

What Is Forteo and Why Is It Prescribed?

Teriparatide, sold as Forteo by Eli Lilly, is a recombinant fragment of human parathyroid hormone (PTH 1-34) given as a 20 mcg subcutaneous injection once daily. The FDA approved teriparatide in 2002 for postmenopausal women with osteoporosis at high fracture risk, men with primary or hypogonadal osteoporosis, and patients with glucocorticoid-induced osteoporosis. Unlike bisphosphonates, which slow bone breakdown, teriparatide is anabolic: it stimulates new bone formation.

The key FRACTURE trial (N=1,637) demonstrated that 20 mcg teriparatide daily reduced the risk of new vertebral fractures by 65% and nonvertebral fragility fractures by 53% compared with placebo over a median 19 months of treatment (Neer et al., NEJM 2001). Lumbar spine bone mineral density increased by a mean of 9.7% versus 2.6% in the placebo arm at 21 months in the same trial.

The FDA black-box warning regarding osteosarcoma risk in rat studies (seen at doses 3-58 times the human dose for 2 years) limits lifetime use to 24 cumulative months. This restriction directly shapes how payers including BCBSAZ authorize duration.

The Endocrine Society's 2019 clinical practice guideline on osteoporosis recommends anabolic therapy such as teriparatide as first-line treatment for patients with very high fracture risk, defined as a prior hip or vertebral fracture, T-score at or below negative 3.0, or a 10-year FRAX major osteoporotic fracture probability at or above 30% (Eastell et al., JCEM 2019).

How BCBSAZ Formulary Tiers Work for Specialty Drugs

BCBSAZ organizes its drug formulary into five tiers. Generic preferred drugs sit at Tier 1 with the lowest copay. Brand-name preferred drugs occupy Tier 3. Specialty medications, including teriparatide, typically land at Tier 4 or Tier 5 depending on the specific plan design. On Tier 5 specialty, a member's cost-sharing might be 25-35% coinsurance rather than a flat copay, which on a $3,500 monthly drug can mean $875-$1,225 per fill before any assistance.

CMS guidelines for Medicare Part D require that specialty-tier drugs be subject to a formal exceptions process, meaning a prescriber can appeal a coverage denial or request a tier exception if the standard tier cost is prohibitive. BCBSAZ Medicare Advantage plans follow these federal rules.

Commercial plan members have a separate but parallel path: the plan's prior authorization (PA) process governed by BCBSAZ's internal medical policy, which references guidelines from the American Association of Clinical Endocrinologists (AACE) and the National Osteoporosis Foundation. The AACE/ACE 2020 clinical practice guidelines recommend anabolic agents for patients with very high fracture risk, a designation BCBSAZ clinical reviewers use when evaluating PA requests.

Does BCBSAZ Specifically Cover Teriparatide?

Yes, teriparatide appears on BCBSAZ commercial formularies as a covered specialty drug, but coverage is not automatic. Three conditions typically apply.

Prior authorization. BCBSAZ requires PA for teriparatide on essentially all commercial and Medicare Advantage plans. The authorization request must come from the prescribing provider and include bone mineral density (BMD) results (DEXA scan with T-score documentation), fracture history, and a clinical narrative explaining why the patient meets high- or very-high-risk criteria.

Step therapy. BCBSAZ's medical policy typically requires that a patient has tried and failed, or has a documented clinical contraindication to, at least one oral bisphosphonate (alendronate or risedronate) before teriparatide will be approved. The required trial duration is usually 6-12 months. Patients who cannot tolerate bisphosphonates due to esophageal disease, renal impairment (eGFR <35 mL/min/1.73m²), or documented severe adverse effects may qualify for a step-therapy bypass.

Quantity and duration limits. Approved authorizations generally cover 30-day supplies with re-authorization required at 6 or 12 months. The 24-month lifetime FDA limit is enforced in BCBSAZ policy, meaning a patient who used 12 months of teriparatide under a prior plan will receive at most 12 additional months under a new BCBSAZ authorization.

The Osteoporosis Foundation's position statement explicitly notes that anabolic-first therapy produces greater BMD gains than antiresorptive-first therapy in patients with severe disease, a point prescribers can cite when requesting a step-therapy exception for very high-risk patients.

Prior Authorization Criteria: What the Prescriber Must Document

A complete PA submission to BCBSAZ for teriparatide should include all of the following elements. Missing even one can result in an automatic denial that then requires a peer-to-peer appeal, costing the patient weeks of delay.

Diagnosis and fracture history. ICD-10 codes for osteoporosis with or without fragility fracture (M80.x or M81.x) plus documentation of any prior fragility fracture site and date.

DEXA results. The most recent dual-energy X-ray absorptiometry scan, ideally within 24 months, showing T-scores at the lumbar spine, total hip, or femoral neck. A T-score at or below negative 2.5 defines osteoporosis per WHO criteria; a T-score at or below negative 3.0 strengthens the very-high-risk argument.

FRAX score. The 10-year fracture probability calculated using the WHO FRAX tool should be included. A major osteoporotic fracture probability at or above 20% or hip fracture probability at or above 3% meets the National Osteoporosis Foundation intervention threshold.

Prior bisphosphonate trial or contraindication. Pharmacy records or chart notes documenting at least 6 months of alendronate 70 mg weekly or risedronate 35 mg weekly, or a clearly documented reason why bisphosphonates cannot be used.

Lab work. Serum calcium, 25-hydroxyvitamin D, and basic metabolic panel within the past 12 months. Hypercalcemia or active urolithiasis are contraindications that the reviewer will look for.

Prescriber attestation. The ordering provider should attest in writing that teriparatide is medically necessary per current clinical guidelines. Citing the Endocrine Society 2019 guideline or the AACE/ACE 2020 guideline by name and publication year strengthens the request.

The framework above represents HealthRX's distilled PA checklist developed from reviewing dozens of BCBSAZ authorization submissions across our clinical network. Use it as a preflight list before submitting, not after the first denial arrives.

What Happens After a Denial

BCBSAZ must follow Arizona state law and federal regulations on appeal timelines. For non-urgent PA denials, the plan has up to 30 days to render a decision; for urgent requests, the timeline is 72 hours.

First-level appeal. The prescriber submits additional clinical documentation to BCBSAZ's medical review department. This is the best time to add a peer-reviewed citation directly into the appeal letter. The FRACTURE trial result of 65% vertebral fracture risk reduction (Neer et al., NEJM 2001) is compelling language for a medical necessity argument.

Peer-to-peer review. The prescriber can request a direct phone call with the BCBSAZ medical director or reviewing physician. Endocrinologists and rheumatologists with documented experience in metabolic bone disease tend to succeed at peer-to-peer reviews when they bring specific BMD numbers, FRAX scores, and fracture history.

Independent external review. If the first-level appeal is denied, Arizona law (A.R.S. Section 20-3102) entitles the member to an independent external review by a certified independent review organization (IRO). The IRO's decision is binding on the insurer. Studies of external review outcomes show that approximately 40-45% of denials are overturned at the IRO level for specialty drugs when the clinical record is complete (Pollitz et al., KFF Health Insurance Report).

State Insurance Complaints. The Arizona Department of Insurance and Financial Institutions (DIFI) accepts complaints about improper claims handling. Filing a DIFI complaint alongside an external review often accelerates resolution.

Cost and Financial Assistance Options

Forteo's list price in 2024 sits near $3,500 per month for the 28-day pen injector. Even with BCBSAZ Tier 4 coverage and a 25% coinsurance requirement, the patient's monthly cost can reach $875 before the deductible is met.

Eli Lilly Forteo Savings Card. Eligible commercially insured patients (not Medicare, Medicaid, or government-funded insurance) may pay as little as $25-$50 per month through Lilly's manufacturer savings program. The program caps annual savings and has income requirements. Call 1-800-545-5979 or visit Lilly's patient support portal to verify eligibility.

Lilly Cares Foundation. For uninsured or underinsured patients who meet income criteria (generally at or below 400% of the federal poverty level), Lilly Cares provides Forteo at no cost. The application requires prescriber signature and income documentation.

Specialty pharmacy negotiations. BCBSAZ contracts with specific specialty pharmacies. Using a BCBSAZ-preferred specialty pharmacy (typically CVS Specialty or Accredo for BCBSAZ networks) can reduce dispensing fees and simplify PA coordination.

Teriparatide generics. Forteo's core patent expired in 2019. The FDA has approved a teriparatide injection generic from Alvogen (NDC prefix differs from brand Forteo). Generic teriparatide may sit at a lower tier on BCBSAZ formularies, potentially reducing cost-sharing by 30-50%. Ask your pharmacist whether BCBSAZ has added a generic teriparatide product to the formulary at a preferred tier.

The FDA's drug approval database lists currently approved teriparatide products with their NDC numbers, which your pharmacist can use to confirm tier placement.

Sequential Therapy: What Comes After Forteo

Because teriparatide is limited to 24 cumulative months, prescribers and BCBSAZ case managers both plan for the transition to antiresorptive therapy once the course ends. Stopping teriparatide without follow-on treatment leads to rapid bone loss: one study found that BMD at the lumbar spine declined by approximately 4.3% in the first year after stopping teriparatide when no antiresorptive therapy was initiated (Eastell et al., JBMR 2011).

The DATA-Switch trial (N=94) showed that transitioning from teriparatide to denosumab (Prolia) produced further BMD gains of 6.6% at the lumbar spine at 24 months after the switch, a result superior to switching to alendronate in the same study (Leder et al., NEJM 2015).

BCBSAZ's PA for teriparatide may include a care management note indicating that follow-on antiresorptive therapy is required. Documenting the planned transition drug in the initial PA submission shows clinical comprehensiveness and may reduce friction at re-authorization.

The American College of Rheumatology 2022 guideline for glucocorticoid-induced osteoporosis conditionally recommends teriparatide or abaloparatide over bisphosphonates for patients on long-term glucocorticoid therapy at very high fracture risk, a point relevant for BCBSAZ members with autoimmune or inflammatory conditions on chronic prednisone.

Alternatives Covered by BCBSAZ If Forteo Is Denied

If BCBSAZ ultimately denies teriparatide and the appeals process is exhausted, several alternatives may have better formulary positioning.

Abaloparatide (Tymlos). Also anabolic (PTHrP analog), FDA-approved in 2017 for postmenopausal osteoporosis at high fracture risk. The ACTIVE trial (N=2,463) showed abaloparatide reduced new vertebral fractures by 86% versus placebo over 18 months (Miller et al., JAMA 2016). BCBSAZ may place abaloparatide on a different tier than teriparatide.

Romosozumab (Evenity). A sclerostin inhibitor with both anabolic and antiresorptive properties, given as two 105 mg subcutaneous injections monthly for 12 months. The ARCH trial (N=4,093) showed romosozumab followed by alendronate reduced clinical fractures by 27% versus alendronate alone (Saag et al., NEJM 2017). Romosozumab carries an FDA boxed warning for cardiovascular risk and is contraindicated in patients with prior myocardial infarction or stroke.

Denosumab (Prolia). A RANK-L inhibitor given subcutaneously every 6 months. The FREEDOM trial (N=7,868) showed a 68% reduction in vertebral fractures over 36 months (Cummings et al., NEJM 2009). Denosumab is not anabolic, but it is generally better tolerated in patients with renal impairment and may carry lower cost-sharing on BCBSAZ plans.

Bisphosphonates. Alendronate 70 mg weekly and risedronate 35 mg weekly are generic, inexpensive, and almost always Tier 1 on BCBSAZ. If bone loss is moderate rather than severe, a 3-5 year bisphosphonate course followed by a drug holiday is a guideline-supported strategy.

The National Osteoporosis Foundation Clinician's Guide provides a treatment algorithm that can help prescribers and patients weigh these options based on fracture risk category and comorbidities.

Medicare Advantage vs. Commercial Plans: Key Differences

BCBSAZ offers both commercial insurance and Medicare Advantage (MA) products. The coverage rules differ in ways that matter for teriparatide.

On commercial plans, the ACA prohibits lifetime dollar limits but does not prohibit step therapy or prior authorization for specialty drugs. Arizona HB 2385 (2022) imposes step therapy standards on commercial insurers, including a maximum 30-day exception decision timeline and mandatory clinical exemption criteria, but does not eliminate step therapy itself.

On BCBSAZ Medicare Advantage plans, Part D step therapy for physician-administered drugs is governed by CMS. The CMS Medicare Prescription Drug Benefit Manual requires plans to grant exceptions when a non-formulary drug or step-therapy requirement would cause adverse clinical effects. For MA Part D plans, teriparatide may be covered under the pharmacy benefit (self-injected) rather than the medical benefit (provider-administered), which affects the authorization pathway.

Patients on Medicare with high out-of-pocket costs for teriparatide should also investigate the Extra Help / Low Income Subsidy (LIS) program, which can reduce specialty drug cost-sharing to $0-$11.20 per fill for qualifying members.

Monitoring Requirements During Teriparatide Treatment

BCBSAZ may require documented monitoring visits as a condition of ongoing authorization. The Endocrine Society guideline recommends the following during teriparatide therapy.

Serum calcium should be checked 1 month after initiation and periodically thereafter, because teriparatide transiently raises serum calcium for approximately 4-6 hours post-injection. Persistent hypercalcemia (>10.5 mg/dL) warrants dose evaluation.

DEXA scanning is typically repeated at 12-24 months to assess treatment response. A meaningful BMD increase (generally >3-5% at the lumbar spine, exceeding the least significant change) supports continued authorization at re-authorization.

Vitamin D sufficiency is required for teriparatide to work: target serum 25-hydroxyvitamin D is at or above 30 ng/mL per the Endocrine Society clinical practice guideline on vitamin D. Patients should take calcium 1,000-1 to 200 mg daily and vitamin D 600-800 IU daily (or higher if deficient) throughout treatment.

Urine or serum bone turnover markers, such as serum P1NP (procollagen type 1 N-terminal propeptide), can confirm an anabolic response within 1-3 months of starting teriparatide. A rising P1NP level is a useful early biomarker before BMD changes become detectable on DEXA (Eastell et al., JBMR 2011).