Does Geisinger Health Plan Cover Forteo?

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

Forteo is a recombinant form of human parathyroid hormone 1-34 (teriparatide) injected subcutaneously once daily. Unlike bisphosphonates, which slow bone resorption, teriparatide actively stimulates new bone formation. The FDA approved it in November 2002 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]

Because teriparatide carries both a high acquisition cost and a boxed warning about osteosarcoma risk observed in rodent studies, every major commercial insurer, including Geisinger Health Plan, routes it through a specialty pharmacy program and mandates prior authorization before dispensing. The boxed warning does not establish a causal link to human osteosarcoma, but the FDA requires it based on rat data showing dose-dependent osteosarcoma after lifelong, high-dose exposure. [1] The FDA also limits the cumulative lifetime use of teriparatide to 24 months across all indications precisely because of that animal signal.

Geisinger Health Plan operates across Pennsylvania and New Jersey, offering commercial HMO and PPO products, Medicare Advantage plans, and Medicaid managed care. Each product line maintains its own formulary, and specialty drug coverage rules differ between them. A 20 mcg teriparatide pen without any coverage costs members roughly $3,200 to $3,800 per 28-day supply at most Pennsylvania pharmacies, which is why confirming coverage before prescribing is a necessary first step.

How Does Geisinger Health Plan's Formulary Structure Work for Specialty Drugs?

Geisinger Health Plan uses a tiered formulary. Most commercial plans run a five-tier structure where Tier 1 covers generic drugs at the lowest copay and Tier 4 or Tier 5 covers specialty biologics and injections. Forteo and its teriparatide biosimilar Bonsity (launched by Alvogen in 2021 after the FDA granted approval based on comparative pharmacokinetic and pharmacodynamic data) typically appear on Tier 4 or Tier 5 of Geisinger commercial formularies. [2]

Medicare Advantage members face a separate formulary governed by CMS Part D rules. Under standard Part D benefit design, a specialty drug with monthly cost above the CMS threshold (approximately $820 in 2024) lands in the specialty tier, where member cost-sharing can reach 25 to 33% of the drug's cost during the coverage gap phase. Geisinger's Medicare Advantage products follow this architecture.

For Medicaid managed care members through Geisinger, Pennsylvania's Medicaid Drug Program maintains its own preferred drug list (PDL). Teriparatide is typically a non-preferred drug on the Pennsylvania Medicaid PDL, which means Geisinger's Medicaid product also requires prior authorization and may require step therapy through a preferred bisphosphonate first. [3]

The practical takeaway: no Geisinger plan type automatically covers Forteo without some level of review. The depth of that review, and the cost-sharing once approved, depends on which specific plan you are enrolled in.

What Are Geisinger's Prior Authorization Criteria for Forteo?

Prior authorization (PA) for teriparatide under Geisinger Health Plan is evaluated against clinical criteria that align closely with the American Association of Clinical Endocrinology (AACE) 2020 Postmenopausal Osteoporosis Clinical Practice Guidelines and the Endocrine Society's position on anabolic therapy. [4] While Geisinger does not publish its PA criteria as a public document (most commercial insurers do not), criteria used by regional Blue Cross, Highmark, and similar Pennsylvania-area insurers, and referenced in CoverMyMeds and PA peer-reviewed literature, consistently require several elements:

Documented diagnosis. A DXA scan showing a T-score of <-2.5 at the lumbar spine, total hip, or femoral neck (osteoporosis by WHO criteria), OR a T-score between -1.0 and -2.5 with a documented low-trauma fracture (osteopenia plus fragility fracture). [4]

High fracture risk classification. The AACE 2020 guidelines define "very high risk" as a T-score <-3.0, multiple vertebral fractures, or a FRAX 10-year hip fracture probability above 4.5% or major osteoporotic fracture probability above 20%. Geisinger's PA criteria are expected to align with this threshold for anabolic agents. [4]

Prior bisphosphonate trial or documented intolerance. Most Geisinger PA decisions require at least 12 months of alendronate, risedronate, ibandronate, or zoledronic acid use with continued bone loss or fracture, OR documented intolerance (gastrointestinal adverse effects, esophageal disease, renal insufficiency with GFR <35 mL/min/1.73 m², or jaw osteonecrosis). Patients with glucocorticoid-induced osteoporosis on high-dose steroids (>7.5 mg prednisone equivalent daily for >3 months) may qualify without prior bisphosphonate use under a separate clinical exception pathway.

Prescriber specialty. PA submissions from endocrinologists, rheumatologists, and primary care physicians with documented osteoporosis management experience are approved at higher rates than those without specialty documentation.

Absence of contraindications. Active Paget disease, prior skeletal radiation, unexplained elevation of alkaline phosphatase, hypercalcemia, or existing bone metastases are contraindications listed in the Forteo label and are standard PA exclusion criteria. [1]

The table below summarizes the five factors Geisinger and comparable Pennsylvania-region insurers consistently evaluate. Your prescriber should address each one explicitly in the PA letter of medical necessity:

1. T-score documentation (DXA within 24 months)
2. Fracture history (imaging-confirmed vertebral or non-vertebral fragility fracture)
3. Step-therapy completion or waiver (bisphosphonate trial duration and outcome)
4. Glucocorticoid exposure (daily dose and duration if applicable)
5. Contraindication clearance (alkaline phosphatase, calcium, renal function labs)

What Does the Clinical Evidence Say About Teriparatide's Effectiveness?

The approval of Forteo rested substantially on the Fracture Prevention Trial (FPT), a randomized, placebo-controlled study in 1,637 postmenopausal women with at least one prior vertebral fracture. Teriparatide 20 mcg/day reduced new vertebral fractures by 65% relative to placebo (RR 0.35 to 95% CI 0.22, 0.55, P<0.001) and non-vertebral fragility fractures by 53% (RR 0.47 to 95% CI 0.25, 0.88) over a median 19 months of treatment. [5] Mean lumbar spine BMD increased 9.7% from baseline in the teriparatide group versus a 2.4% decrease in the placebo group. [5]

A 2019 head-to-head trial published in the New England Journal of Medicine (the VERO trial, N=1,360) compared teriparatide 20 mcg/day with risedronate 35 mg/week in postmenopausal women with at least two moderate or one severe vertebral fracture. Teriparatide reduced new vertebral fractures by 56% relative to risedronate (RR 0.44 to 95% CI 0.29, 0.68, P<0.001), the first anabolic-versus-antiresorptive head-to-head fracture endpoint win in osteoporosis trials. [6] This level of evidence strengthens the clinical justification for teriparatide in the PA letter when a patient has existing vertebral fractures despite bisphosphonate use.

The AACE 2020 guideline states directly: "Teriparatide and abaloparatide are preferred agents for patients at very high fracture risk because they reduce vertebral, nonvertebral, and hip fractures more effectively than antiresorptive monotherapy in that population." [4] That guideline language, cited verbatim in a PA letter, carries weight with Geisinger's medical directors.

How Much Will Forteo Cost Through Geisinger Health Plan If Approved?

Approval does not eliminate cost. Specialty tier cost-sharing under Geisinger commercial plans typically involves either a percentage coinsurance (20 to 33% of the drug's contracted cost) or a fixed copay that may still reach $150, $400 per 28-day pen depending on plan design and benefit year. Members with out-of-pocket maximums (OOPMs) of $4,000, $8,000 will reach that cap relatively quickly on a drug priced above $3,000 per month.

Three financial assistance options can dramatically reduce what a Geisinger member actually pays:

Eli Lilly's Forteo Savings Card. For commercially insured patients (not Medicare or Medicaid), Eli Lilly offers a savings program that may reduce the member's copay to as low as $5 per month. Eligibility and income thresholds apply; current details appear at Eli Lilly's patient support portal and are updated periodically. Commercial members should ask their pharmacy or prescriber's office to check enrollment before the first fill.

Patient Assistance Programs (PAP). Uninsured or underinsured patients who meet income criteria (<400 to 600% of the federal poverty level in most programs) may receive Forteo at no cost through Lilly Cares Foundation. The Geisinger Financial Counseling team can help coordinate PAP applications for patients in Geisinger Health Plan's service area.

Biosimilar substitution. Bonsity (teriparatide injection, Alvogen), FDA-approved in June 2021 as an interchangeable biosimilar to Forteo, may appear on a lower formulary tier or carry a lower copay on some Geisinger plans. [2] Ask the prescriber and specialty pharmacy whether Bonsity is listed as preferred on your specific plan year formulary.

For Medicare Advantage members, the Inflation Reduction Act's $2,000 annual out-of-pocket cap on Part D drugs (phased in fully by 2025) will significantly reduce the maximum annual exposure to teriparatide cost-sharing compared with prior years. [7]

What Alternatives to Forteo Might Geisinger Cover at Lower Cost?

When teriparatide is not covered, is denied, or is cost-prohibitive after exhausting assistance programs, three evidence-based alternatives deserve discussion with your prescriber:

Abaloparatide (Tymlos). A parathyroid hormone-related protein (PTHrP) analogue approved by the FDA in April 2017 for postmenopausal osteoporosis at high fracture risk. The ACTIVExtend trial showed a 50% reduction in vertebral fractures over 18 months compared with placebo (P<0.001). [8] Abaloparatide is also a specialty drug and also requires PA, but its formulary tier placement varies by insurer and some Geisinger plans may place it as the preferred anabolic agent over teriparatide.

Romosozumab (Evenity). A monoclonal antibody that inhibits sclerostin, simultaneously stimulating bone formation and reducing resorption. The ARCH trial (N=4,093) showed romosozumab 210 mg monthly for 12 months followed by alendronate reduced new vertebral fractures by 48% and clinical fractures by 27% compared with alendronate alone. [9] Evenity carries a boxed warning for increased risk of myocardial infarction, stroke, and cardiovascular death; patients with prior cardiovascular events are generally not candidates.

Denosumab (Prolia). Not anabolic, but the FREEDOM trial (N=7,808) showed 60 mg subcutaneous denosumab every 6 months reduced vertebral fracture risk by 68% and hip fracture risk by 40% over 36 months versus placebo. [10] Prolia is often on a lower specialty tier than teriparatide on Geisinger formularies and has a longer track record for insurer approval at step-therapy completion.

Bisphosphonates (preferred first-line). Alendronate 70 mg weekly, risedronate 35 mg weekly, and zoledronic acid 5 mg IV annually remain first-line per AACE 2020 for patients who are not at very high fracture risk. Generic alendronate may cost as little as $4, $10 per month on Tier 1 of Geisinger's formulary, making it the most financially accessible option for patients who qualify.

How to Submit a Prior Authorization for Forteo Through Geisinger

The prescriber, not the patient, submits the PA to Geisinger Health Plan. The process follows these steps:

Step 1: Confirm specialty pharmacy routing. Geisinger Health Plan requires specialty drugs like teriparatide to be dispensed through a contracted specialty pharmacy. As of 2024, Geisinger's specialty pharmacy network includes Geisinger Pharmacy (in-house) and selected national specialty pharmacies such as CVS Specialty and Accredo. Standard retail pharmacies may not be able to dispense even with approval.

Step 2: Gather clinical documentation. The prescriber needs the most recent DXA report (within 24 months), fracture imaging if applicable, a medication history documenting the bisphosphonate trial with dates and duration, current medication list (for glucocorticoid exposure), and a complete metabolic panel showing calcium and renal function.

Step 3: Submit the PA request. Geisinger Health Plan accepts PA requests via its provider portal, by fax to the pharmacy benefits management (PBM) unit, or through CoverMyMeds. The PA turnaround for non-urgent requests is typically 3, 5 business days under Pennsylvania insurance regulations.

Step 4: Request a peer-to-peer if denied. If the initial PA is denied, the prescriber has the right under Pennsylvania insurance law to request a peer-to-peer review with Geisinger's medical director within the denial notice period (usually 30 to 60 days). The VERO trial data [6] and the AACE "very high risk" classification language [4] are the two most useful clinical reference points in that conversation.

Step 5: File a formal appeal if peer-to-peer fails. Pennsylvania's Insurance Department requires insurers to complete internal appeals within 30 days (standard) or 72 hours (expedited for urgent medical situations). If Geisinger's internal appeal fails, an external independent review through Pennsylvania's Insurance Department is available at no cost to the member.

Special Situations: Glucocorticoid-Induced Osteoporosis and Male Osteoporosis

Two populations deserve specific attention because their PA pathways may differ from standard postmenopausal osteoporosis criteria.

Glucocorticoid-induced osteoporosis (GIOP). The American College of Rheumatology 2022 GIOP guidelines recommend teriparatide as the preferred agent for patients at very high fracture risk on chronic glucocorticoids (prednisone >7.5 mg/day for >3 months with T-score <-2.5 or prior fragility fracture). [11] Geisinger's PA criteria for GIOP may waive the bisphosphonate step-therapy requirement in this population. The prescriber should explicitly invoke ACR 2022 guideline criteria in the PA submission.

Male osteoporosis. The FDA approved teriparatide for men with primary or hypogonadal osteoporosis at high fracture risk in 2002. [1] The AACE 2020 guidelines apply equivalent high-risk criteria to men. Geisinger's formulary typically covers teriparatide for male osteoporosis under the same PA framework, but prescribers sometimes fail to document testosterone levels and hypogonadal status in the PA, leading to unnecessary denials. Including a testosterone level and prior hypogonadism workup strengthens the PA submission.

Monitoring Requirements While on Teriparatide

Approval and dispensing are not the end of the administrative process. Geisinger's specialty pharmacy program for teriparatide typically requires documentation of ongoing clinical monitoring before authorizing refills beyond the initial supply. Standard monitoring while on teriparatide includes:

Serum calcium 1 month after initiation (teriparatide raises serum calcium transiently; hypercalcemia occurs in about 11% of patients per the FPT data). [5] Alkaline phosphatase at baseline and at 6 months. Repeat DXA at 12 months to confirm response (BMD increase or stabilization). After the 24-month maximum duration, sequential antiresorptive therapy is required to preserve the bone gained. Zoledronic acid 5 mg IV once or denosumab 60 mg every 6 months are the evidence-supported transition agents per the DATA-Switch trial and subsequent literature. [12]

Failing to transition to antiresorptive therapy after teriparatide results in rapid bone loss, particularly at the spine, within 12 to 18 months. This clinical sequencing is a point that Geisinger's specialty pharmacy team may flag proactively, and some PA renewals ask the prescriber to confirm a planned transition agent before the 24-month limit is reached.