Does Health Net Cover Forteo (Teriparatide)?

What Is Forteo and Why Does Coverage Matter?

Forteo is an anabolic bone-building agent, not an antiresorptive, and that distinction shapes both its clinical use and its insurance tier. The FDA approved teriparatide (Forteo) in November 2002 for postmenopausal women with osteoporosis at high fracture risk, men with primary or hypogonadal osteoporosis, and patients with glucocorticoid-induced osteoporosis [1]. Because it stimulates new bone formation rather than simply slowing resorption, it occupies a separate pharmacologic class from bisphosphonates such as alendronate (Fosamax) or risedronate (Actonel).

That clinical distinction carries a price penalty. Forteo's wholesale acquisition cost runs roughly $3,400 per 28-day pen at current rates, placing it among the most expensive osteoporosis drugs on the market [2]. Health Net, like most payers, responds by placing it on a specialty tier with substantial cost-sharing and mandatory prior authorization. Patients who do not manage the authorization process correctly often receive a denial on the first claim, even when the prescription is medically appropriate.

Understanding Health Net's specific coverage criteria is therefore not an academic exercise. Osteoporosis affects approximately 10.2 million Americans age 50 and older, and hip fractures carry a one-year mortality rate near 20% in older adults [3]. Getting coverage right determines whether a high-risk patient actually fills the prescription.

The National Osteoporosis Foundation (now the Bone Health and Osteoporosis Foundation) states in its 2022 Clinician's Guide: "Pharmacologic treatment should be offered to postmenopausal women and men age 50 and older who present with a hip or vertebral fracture or a T-score of -2.5 or lower at the femoral neck, total hip, or lumbar spine." [4] Health Net's medical policies generally align with this threshold but add the step-therapy layer on top.

How Health Net Formularies Classify Forteo

Health Net operates multiple distinct plan types, and formulary placement differs across them. The drug consistently lands on a specialty tier, but cost-sharing percentages vary.

On Health Net commercial HMO and PPO plans offered through Covered California and employer groups, Forteo typically appears on Tier 4 or Tier 5. Tier 4 specialty cost-sharing on many Health Net plans runs 25 to 33% coinsurance after the deductible, which translates to $800, $1,100 per month in member cost-sharing before any copay assistance [5]. Some plans cap specialty out-of-pocket per fill; others do not.

Health Net Medicare Advantage plans follow Part D formulary rules. Under standard Part D benefit design for 2024, specialty drugs in the catastrophic phase cost the enrollee 5% coinsurance, but in the coverage-gap phase the member pays 25% of the drug's cost [6]. Because Forteo crosses the initial coverage limit quickly (the 2024 Part D initial coverage limit is $5 to 030 in total drug spending), most Medicare beneficiaries move through the coverage gap within the first two to three months of the plan year.

Health Net Medi-Cal managed care (California's Medicaid program) covers teriparatide through the specialty pharmacy benefit, subject to Drug Utilization Review criteria published by the Department of Health Care Services [7]. The state's preferred drug list generally requires failure of two bisphosphonates before approving teriparatide unless the patient has a documented contraindication.

Prior Authorization Criteria Health Net Typically Requires

Prior authorization for Forteo under Health Net commercial plans generally demands documentation across four domains. Meeting all four is the clinical standard a prescriber must satisfy to secure approval.

1. Diagnosis confirmation. A DXA scan showing a T-score of -2.5 or lower at the hip or spine, or documented fragility fracture (hip, vertebral, or wrist fracture from a standing-height fall), is required [4]. Health Net medical policy language typically mirrors the BHOF 2022 guideline threshold.

2. High fracture risk designation. A FRAX 10-year probability of major osteoporotic fracture at or above 20%, or hip fracture probability at or above 3%, qualifies as high risk per National Osteoporosis Foundation criteria [4]. Some Health Net reviewers also accept a T-score of -3.0 or lower as automatically high risk without a FRAX calculation.

3. Step therapy. Most Health Net plans require documented trial and failure of, or intolerance to, at least one oral bisphosphonate. Alendronate 70 mg weekly or risedronate 35 mg weekly are the usual first-line agents [8]. Failure is defined as incident fracture during therapy, continued bone mineral density decline of 5% or more at a monitored site, or a documented adverse effect such as osteonecrosis of the jaw, atypical femur fracture, or severe esophageal irritation [9]. Patients with active Paget's disease, prior radiation therapy involving the skeleton, unexplained elevation of alkaline phosphatase, open growth plates, or hypercalcemia are generally exempt from step therapy [1].

4. Prescriber specialty. Health Net may require the prescription to originate from, or be co-signed by, an endocrinologist, rheumatologist, or geriatrician for certain plan types. Primary care physicians can often prescribe teriparatide, but checking the specific plan's medical policy before submitting avoids a specialty routing denial.

The prior authorization is typically valid for 12 months and must be renewed. Because the FDA label limits teriparatide to a cumulative 2-year lifetime course, a patient will need at most two authorization cycles [1].

The Step Therapy Requirement in Detail

Step therapy is the single most common reason Health Net denies a first Forteo claim. The bisphosphonate trial period Health Net requires is usually defined as 3 to 6 months of documented use, though some plan documents specify 90 days of continuous dispensing.

Bisphosphonates reduce vertebral fracture risk by approximately 40 to 70% in randomized trials. The Fracture Intervention Trial (N=2,027) showed alendronate reduced morphometric vertebral fractures by 47% over 3 years compared with placebo [10]. That efficacy makes them a defensible first-line requirement from a payer standpoint.

However, certain patients are not appropriate candidates for bisphosphonate step therapy. Documented contraindications Health Net's policy language typically accepts include:

• Creatinine clearance below 35 mL/min (renal insufficiency contraindicating oral bisphosphonates per prescribing information) [8]
• Barrett's esophagus or active esophageal disease
• Inability to remain upright for 30 minutes after dosing
• Hypocalcemia

If the patient has one of these contraindications, the prescriber should document it explicitly in the prior authorization request and attach the relevant lab values or endoscopy reports. Submitting the contraindication without the supporting documentation is a common avoidable failure point.

For patients who lack a contraindication and have not yet tried a bisphosphonate, the fastest path to Forteo coverage is often completing a short bisphosphonate trial with close monitoring rather than pursuing a step therapy exception appeal, which can take 30 to 60 days [11].

How Much Will Forteo Cost With Health Net Coverage?

Even with coverage approved, out-of-pocket costs are substantial without secondary assistance. Here is a breakdown by plan type.

Commercial plans. With a Tier 4 specialty coinsurance of 30% and a retail price near $3,400, the member portion before the out-of-pocket maximum is approximately $1,020 per fill. Once the plan's annual out-of-pocket maximum is met (typically $4,500, $8,700 for individual coverage on ACA-compliant plans), subsequent fills are $0 [5].

Medicare Advantage Part D. The 2024 Inflation Reduction Act changes cap Medicare Part D out-of-pocket spending at $3,500 for 2024 and $2,000 for 2025, which meaningfully reduces the exposure for Medicare beneficiaries on costly specialty drugs [6]. Health Net Medicare Advantage plan members should verify whether their specific plan uses the standard benefit or an enhanced benefit design with lower specialty tiers.

Medi-Cal. Covered beneficiaries pay $0 to $3.50 per fill once Medi-Cal approves teriparatide through the specialty pharmacy channel [7].

Manufacturer Copay Assistance

Eli Lilly's Lilly Cares Foundation Copay Card can reduce out-of-pocket costs to as little as $0 per month for commercially insured patients who qualify. Income limits and eligibility criteria apply. Medicare beneficiaries are not eligible for manufacturer copay cards due to federal anti-kickback rules, but they may qualify for the Lilly Cares Patient Assistance Program, which provides the drug at no cost to qualifying low-income patients [12].

The Partnership for Prescription Assistance (now NeedyMeds) also lists state pharmaceutical assistance programs that can layer with Health Net coverage for Medicare beneficiaries [13].

What Happens When Health Net Denies Forteo?

A denial is not a final answer. Two formal pathways exist: internal appeal and external independent medical review.

Internal appeal. The member or prescriber has 180 days from the denial notice date to file an internal appeal with Health Net. California law requires Health Net to resolve standard appeals within 30 days and urgent appeals within 3 business days [14]. The appeal should include the prescriber's letter of medical necessity, current DXA results, FRAX calculation printout, and any documentation of bisphosphonate failure or contraindication.

Independent Medical Review (IMR). California's Department of Managed Health Care (DMHC) offers independent medical review for any denied claim that the member believes is medically necessary. The IMR process is free to the member, and Health Net must comply with the IMR decision. Approximately 40% of IMR decisions in California result in overturning the plan's denial [14]. Filing an IMR simultaneously with an internal appeal is permitted and often accelerates resolution.

Expedited review. If a patient recently sustained a vertebral fracture or has a T-score below -3.5 with imminent fracture risk, the prescriber can request expedited review. Health Net must issue an expedited determination within 72 hours [14].

FDA-Approved Alternatives to Forteo That Health Net May Prefer

If step therapy or cost is a barrier, several alternatives carry FDA approval for osteoporosis and may sit on lower Health Net formulary tiers.

Bonsity (teriparatide-tsze). Approved by the FDA in September 2021, Bonsity is a biosimilar to Forteo with the same 20 mcg/day dose and mechanism [15]. Health Net may place Bonsity on a lower specialty tier than the reference product. The launch price was approximately 20% below Forteo's WAC. Prescribers can write "substitution permitted" to allow the pharmacy to dispense Bonsity when it is the preferred teriparatide on Health Net's formulary.

Evenity (romosozumab). The FDA approved romosozumab-aqqg (Evenity) in April 2019 for postmenopausal women with osteoporosis at high fracture risk [16]. The ARCH trial (N=4,093) showed romosozumab followed by alendronate reduced new vertebral fractures by 48% versus alendronate alone over 24 months [17]. Health Net may require the same prior authorization criteria, but some plans tier romosozumab differently than teriparatide.

Prolia (denosumab). Denosumab 60 mg subcutaneously every 6 months is FDA-approved and often sits on a lower specialty tier than teriparatide [18]. The FREEDOM trial (N=7,868) demonstrated a 68% reduction in new vertebral fractures over 36 months versus placebo [19]. Denosumab does not carry the 2-year lifetime limit that teriparatide does, though discontinuation requires a transition plan to prevent rebound bone loss.

Reclast (zoledronic acid). Zoledronic acid 5 mg IV once yearly is another high-efficacy option. HORIZON-PFT (N=7,765) showed a 70% reduction in vertebral fractures over 3 years versus placebo [20]. Annual IV infusion can be easier for patients with gastrointestinal contraindications to oral bisphosphonates, and it may be covered under the medical benefit rather than pharmacy benefit, which can affect cost-sharing significantly.

Sequential and Combination Therapy Considerations

Teriparatide is typically used as monotherapy for its 2-year course, after which antiresorptive therapy is required to maintain gained bone density. The American Association of Clinical Endocrinology 2020 guidelines state: "After completing anabolic therapy, antiresorptive therapy should be initiated to preserve gains in bone mineral density." [21]

The DATA trial (N=94) showed that sequential teriparatide followed by denosumab produced greater gains in spine BMD (+18.3%) than either agent alone at 24 months [22]. Health Net coverage for the subsequent denosumab course requires a separate prior authorization, and the prescriber should file it before the teriparatide course ends to prevent a gap in therapy.

Combination use of teriparatide with denosumab simultaneously (DATA-Switch trial design) showed additive BMD effects but is not FDA-approved as a labeled combination and is unlikely to be covered by Health Net without an off-label use exception request [22].

Monitoring Requirements During Forteo Therapy

Health Net may require documentation of ongoing monitoring to renew the prior authorization at 12 months. Standard monitoring during teriparatide therapy includes:

Serum calcium measured at 1 month after initiation to detect hypercalcemia, which occurs in approximately 3% of patients in clinical trials [1]. A 24-hour urinary calcium is appropriate in patients with a history of nephrolithiasis, as teriparatide increases urinary calcium excretion.

DXA scan at 12 months to document BMD response. A gain of 3% or more at the lumbar spine is considered a positive response, though the absence of a documented gain does not automatically trigger a non-renewal decision. The International Society for Clinical Densitometry recommends DXA monitoring no more frequently than every 1 to 2 years during treatment [23].

Serum bone turnover markers (P1NP or CTX) at 3 months can confirm anabolic response before the DXA interval and are often used in clinical practice to verify adherence and pharmacologic effect [21].

Practical Steps for Prescribers Submitting a Forteo PA to Health Net

A well-organized prior authorization submission reduces denial rates substantially. Based on Health Net's published formulary management criteria and California Department of Managed Health Care guidance, the following documentation bundle is recommended:

1. Completed Health Net specialty drug PA form (available on Health Net's provider portal)
2. Most recent DXA report with T-scores at femoral neck, total hip, and lumbar spine (within 24 months)
3. FRAX calculation printout with the patient's specific inputs
4. Documentation of bisphosphonate trial: pharmacy dispense records or chart notes confirming at least 90 days of use, or a written explanation of contraindication with supporting labs or clinical notes
5. Fracture history: radiology report for any fragility fracture within the past 5 years
6. Letter of medical necessity from the prescribing physician explaining why teriparatide is clinically indicated over available alternatives

Submitting incomplete documentation is the leading cause of first-pass denials. Health Net's specialty pharmacy partner (typically Accredo or Optum Rx depending on the plan type) will request missing items, but each request adds 5, 10 business days to the timeline [11].

Special Populations and Health Net Coverage Nuances

Men with osteoporosis. The FDA label covers men with primary or hypogonadal osteoporosis [1]. Health Net's PA criteria for male patients generally mirror those for postmenopausal women, with total testosterone level documentation added to confirm hypogonadal status when relevant. Testosterone deficiency itself accelerates bone loss, and the Endocrine Society's 2019 guidelines recommend BMD monitoring in men with hypogonadism [24].

Glucocorticoid-induced osteoporosis. Patients on 5 mg or more of prednisone daily for 3 or more months qualify for the glucocorticoid-induced osteoporosis indication [1]. Health Net's PA criteria for this group may require documentation of daily steroid dose and duration. The American College of Rheumatology 2022 guidelines recommend teriparatide over antiresorptives for patients at very high fracture risk on long-term glucocorticoids [25].

Pediatric and premenopausal patients. Teriparatide is not FDA-approved for patients with open epiphyses (generally age <18) or premenopausal women except under rare circumstances [1]. Health Net will not approve teriparatide in pediatric patients, and claims for premenopausal women without a compelling documented rationale will typically be denied.

Cost-Effectiveness Context

Teriparatide's high acquisition cost has generated substantial health economics research. A 2021 analysis published in Osteoporosis International modeled teriparatide versus alendronate in postmenopausal women with prior vertebral fracture and found teriparatide cost-effective at a threshold of $50,000 per quality-adjusted life year (QALY) gained in women with T-scores at or below -3.0 and at least one prior fracture [26]. At higher T-score thresholds, alendronate remained the cost-effective choice. This analysis supports Health Net's step-therapy approach as economically rational for lower-risk patients, while affirming teriparatide's value in the highest-risk tier.

The introduction of Bonsity at a 20% price discount may shift the cost-effectiveness calculations favorably if Health Net negotiates rebates that translate into lower member cost-sharing [15].