Does Highmark Cover Forteo? A Complete Insurance and Clinical Guide

What Is Forteo and Why Is It Prescribed?

Forteo (teriparatide) is a recombinant fragment of human parathyroid hormone (PTH 1-34) that stimulates new bone formation rather than simply slowing bone loss. The FDA approved teriparatide in 2002 for postmenopausal women and men with osteoporosis at high fracture risk, and in 2009 it received an additional indication for glucocorticoid-induced osteoporosis. Teriparatide FDA label

Unlike bisphosphonates such as alendronate or risedronate, teriparatide acts anabolically, meaning it builds new bone matrix. A landmark 2001 randomized controlled trial published in the New England Journal of Medicine (N=1,637 postmenopausal women) found that teriparatide 20 mcg/day reduced the risk of new vertebral fractures by 65% compared to placebo (relative risk 0.35; 95% CI 0.22-0.55; P<0.001) over a median 19 months of treatment. Neer RM et al., NEJM 2001

Nonvertebral fragility fractures fell by 53% in the same trial. Those numbers explain why prescribers reach for teriparatide in patients who fracture on bisphosphonates or who have very low bone density.

The FDA restricts lifetime use to 24 months total because early animal studies showed osteosarcoma at supraphysiologic doses. No causal link to osteosarcoma in humans has been established at therapeutic doses, but the restriction stands. FDA teriparatide safety communication

Because of that 24-month ceiling and the drug's high list price, insurance plans including Highmark apply close scrutiny at the prior authorization stage.

How Highmark Formularies Work for Specialty Drugs

Highmark is a regional Blue Cross Blue Shield affiliate serving Pennsylvania, Delaware, and West Virginia, with commercial, Medicare Advantage, and Medicaid managed care products. Each product line maintains its own formulary, so Highmark Blue Shield PPO, Highmark Community Blue, and Highmark MedAdvantage Rx all carry slightly different tier placements and PA criteria for Forteo.

Specialty drugs are generally placed on Tier 4 (preferred specialty) or Tier 5 (non-preferred specialty). Cost-sharing on specialty tiers typically runs 20-33% coinsurance after deductible, which on a $3,200/month drug translates to $640-$1,056 per month before any manufacturer assistance. CMS specialty drug tier guidance

Highmark publishes its formulary drug lists online; as of 2024, teriparatide (brand Forteo and the biosimilar Bonsity from Radius Health) appears on most commercial plan formularies with a PA requirement notation. Checking your specific plan's formulary document at Highmark.com or calling the pharmacy benefits number on your insurance card is the only way to confirm current tier placement for your plan year.

Does Highmark Cover Forteo? Specific Prior Authorization Criteria

Highmark's standard prior authorization criteria for teriparatide align closely with criteria published by the American Association of Clinical Endocrinology (AACE) and the Endocrine Society. AACE Clinical Practice Guidelines for osteoporosis, 2020

To win PA approval, a prescriber's submission generally must document ALL of the following:

Diagnosis confirmation. A DEXA scan showing a T-score of -2.5 or lower at the spine or hip, OR a history of low-trauma (fragility) fracture, OR both. The 2020 AACE guidelines define "very high fracture risk" as a T-score at or below -3.0, a prior fracture in the past 12 months, or multiple vertebral fractures. Camacho PM et al., Endocrine Practice 2020

Step therapy completion. Most Highmark commercial plans require documented use of an oral bisphosphonate (alendronate, risedronate, or ibandronate) for at least 6-12 continuous months, unless the patient has a documented contraindication or intolerance. Contraindications recognized by Highmark typically include esophageal disorders, severe renal impairment (creatinine clearance <35 mL/min), and documented bisphosphonate-related osteonecrosis of the jaw. NIH osteoporosis treatment review

Prescriber specialty. Some Highmark plans require that the ordering clinician be an endocrinologist, rheumatologist, or orthopedic surgeon, or that the prescriber provide a consultation note confirming high fracture risk assessment. Check the specific plan's PA form.

No concurrent use of denosumab or romosozumab. Highmark will not approve concurrent anabolic and antiresorptive agents used simultaneously for the same indication; sequential use is permitted and often required per guidelines.

Duration and renewal. Initial approvals typically cover 6 months. Renewal authorizations require documentation of tolerability and continued need, up to the FDA-mandated 24-month lifetime maximum. FDA teriparatide prescribing information

What Happens When Prior Authorization Is Denied?

A denial is not the end of the road. Federal law and Pennsylvania state law both guarantee a right to appeal. Here is the sequence:

Internal appeal (first-level). File within 180 days of the denial notice. Your prescriber submits additional clinical documentation: bone density trends, fracture history, imaging reports, and a letter of medical necessity. The appeal must be decided within 30 days for standard requests or 72 hours for urgent/expedited requests under the Highmark Member Rights policy, which mirrors the requirements of 45 CFR 147.136 and the ACA internal appeals rule. CMS internal appeals rules

External independent review. If the internal appeal fails, Pennsylvania law (Act 68 of 1998) requires Highmark to offer an external review by an independent review organization (IRO). The IRO's decision is binding on Highmark. Pennsylvania Insurance Department HMO law overview

Exceptions and step therapy override. The federal Restoring the Patient's Voice Act, enacted in the Consolidated Appropriations Act of 2021, requires Medicare Advantage plans including Highmark's MA products to grant step-therapy exceptions when the clinician documents that the required step-therapy drug is clinically inappropriate. CMS step therapy exceptions guidance

Highmark Medicare Advantage vs. Commercial Coverage

The coverage experience differs meaningfully between Highmark's commercial and Medicare Advantage products.

Medicare Advantage (Part D drug benefit). Forteo falls under Part D. The Centers for Medicare and Medicaid Services require all Part D plans to cover at least two drugs in each therapeutic category, but teriparatide sits in the anabolic bone agent category where there are now multiple agents (teriparatide brand, Bonsity biosimilar, abaloparatide/Tymlos). Your Highmark MA plan may prefer Bonsity over brand Forteo, which could mean a lower specialty tier copay. CMS Part D formulary requirements

A 2022 CMS analysis found that median out-of-pocket costs for specialty-tier drugs under Medicare Part D before the Inflation Reduction Act's $2,000 catastrophic cap reached approximately $3,100 per year for a drug in this price range. Starting in 2025, the $2,000 annual out-of-pocket cap applies to all Part D enrollees, which substantially limits maximum exposure for teriparatide users on Medicare Advantage plans. Medicare Prescription Drug Inflation Reduction Act provisions, CMS

Commercial plans. Employers with Highmark group coverage may or may not include specialty drug coverage. Fully insured small-group plans must follow ACA essential health benefits, which include prescription drugs, but the specific tier and PA criteria are plan-specific. Self-funded employer plans (governed by ERISA) can structure benefits with considerably more flexibility, and some choose to carve out specialty pharmacy to a separate PBM. Ask your HR department whether specialty drugs are managed through Highmark's own pharmacy benefit or through a separate administrator.

Teriparatide Biosimilars: Does Highmark Cover Bonsity?

Bonsity (teriparatide-pbwb) from Radius Health received FDA approval in June 2021 as the first biosimilar to Forteo. FDA Bonsity approval

Many Highmark formularies now place Bonsity on a preferred specialty tier relative to brand Forteo, meaning lower cost-sharing for the patient. Clinically, FDA has determined Bonsity is interchangeable with Forteo; a pharmacist may substitute Bonsity for a Forteo prescription without additional prescriber authorization in states that permit interchangeable biosimilar substitution, including Pennsylvania. FDA interchangeable biosimilars list

If your Highmark plan covers Bonsity at a lower tier, ask your prescriber to write the prescription generically for "teriparatide" and let the specialty pharmacy dispense the preferred product. This single step can meaningfully reduce your monthly cost-sharing.

What Does Forteo Cost With and Without Highmark Coverage?

Without insurance, the 2024 wholesale acquisition cost (WAC) for Forteo is approximately $3,200 per month, or roughly $38,400 per year. The biosimilar Bonsity lists at a discount of approximately 15-18% below Forteo's WAC, still placing it well above most patients' out-of-pocket budgets without insurance.

A 2021 study in JAMA Internal Medicine examining specialty drug out-of-pocket costs found that patients on specialty-tier medications with commercial insurance paid a median of $1,234 per year in cost-sharing, but costs varied widely with a standard deviation exceeding $2,000 per year, reflecting differences in plan design. Dusetzina SB et al., JAMA Intern Med 2021

With Highmark commercial coverage after prior authorization approval:

• Patients with met deductibles often pay 20-33% coinsurance on specialty tier, which on Forteo amounts to roughly $640-$1,056/month before copay assistance.
• Eli Lilly's Forteo Savings Card can reduce commercial plan cost-sharing to as low as $4/month for eligible patients (income and insurance restrictions apply; not available for government-funded plans). Lilly Cares Foundation patient assistance
• Medicare Advantage enrollees are ineligible for manufacturer copay cards but may qualify for the Lilly Cares Foundation Patient Assistance Program if income is below 400% of the federal poverty level.

The Clinical Case for Anabolic Therapy: When Guidelines Say Forteo First

Most Highmark PA criteria require bisphosphonate step therapy, but AACE and the Endocrine Society guidelines specifically recommend anabolic therapy as a first option for patients at "very high fracture risk." The AACE 2020 Clinical Practice Guidelines state: "For patients with very high fracture risk, initial treatment with an anabolic agent is preferred over antiresorptive therapy." Camacho PM et al., Endocrine Practice 2020

This clinical guidance can form the basis for a step-therapy exception request. If your prescriber documents a T-score at or below -3.0, a recent vertebral fracture within 12 months, or multiple prior fractures, the AACE guideline language provides explicit support for bypassing bisphosphonate step therapy.

The DATA-Switch trial published in the Lancet (N=94) demonstrated that transitioning from denosumab to teriparatide produced transient bone loss at the hip, reinforcing that sequence of anabolic and antiresorptive therapy matters clinically and should be individualized. Leder BZ et al., Lancet 2015

The VERO trial (N=1,360) compared teriparatide directly against risedronate in postmenopausal women with at least two vertebral fractures. At 24 months, teriparatide reduced new vertebral fractures by 56% relative to risedronate (P<0.0001) and reduced clinical fractures by 52% (P=0.0,001). Kendler DL et al., Lancet 2018 This head-to-head evidence is exactly the kind of data to include in an appeal package when Highmark has denied Forteo in favor of continued bisphosphonate use.

Glucocorticoid-Induced Osteoporosis: A Separate PA Pathway

Patients taking the equivalent of prednisone 5 mg/day for 3 or more months are at substantially elevated fracture risk independent of DEXA score. The American College of Rheumatology 2022 guidelines recommend teriparatide for patients on high-dose glucocorticoids (>30 mg/day prednisone equivalent for >30 days) who have a moderate-to-high fracture risk. ACR glucocorticoid-induced osteoporosis guidelines 2022 summary, NIH

Highmark's PA criteria for glucocorticoid-induced osteoporosis often include a separate pathway with less stringent step-therapy requirements. A prescriber documenting current high-dose corticosteroid use and a fragility fracture or T-score at or below -2.0 may qualify for expedited approval without a prior bisphosphonate trial.

How to Submit a Highmark Prior Authorization for Forteo

The prescriber or their staff initiates the PA. Here is a checklist of documents that strengthen the submission:

1. Current DEXA report with T-scores at lumbar spine, femoral neck, and total hip, dated within 24 months. ISCD official positions on DEXA, NIH
2. Fracture history including imaging reports (X-ray, CT, or MRI) confirming any vertebral or nonvertebral fractures.
3. Documentation of bisphosphonate trial or written statement of contraindication with clinical rationale.
4. FRAX 10-year fracture probability score if available. WHO FRAX tool
5. A letter of medical necessity referencing the AACE or Endocrine Society guideline language for very-high-risk patients.
6. Current medication list confirming no concurrent anabolic or prohibited combination therapy.
7. If glucocorticoid-induced: documentation of corticosteroid dose, duration, and indication.

Highmark accepts PA submissions through its online NaviNet provider portal, by fax, or through a dedicated specialty pharmacy (typically Accredo or Highmark's preferred specialty pharmacy vendor). Standard PA decisions are required within 3 business days under Pennsylvania regulations; expedited decisions within 24 hours for urgent clinical situations.

Patient Assistance Programs When Coverage Fails

If Highmark denies coverage after exhausting appeals, or if cost-sharing remains unaffordable, three programs exist:

Lilly Cares Foundation Patient Assistance Program. Free Forteo for patients who have no insurance coverage for the drug and whose household income is at or below 400% of the federal poverty level ($60,240 for a single person in 2024). Applications require prescriber completion and typically process within 2-4 weeks. Lilly Cares Foundation

NeedyMeds. A nonprofit database listing additional local and national assistance programs for teriparatide. NeedyMeds teriparatide listing

340B Program. Patients receiving care at a federally qualified health center or other 340B-covered entity may access teriparatide at substantially reduced cost through that entity's pharmacy. HRSA 340B program overview

A pharmacist at a specialty pharmacy that contracts with Highmark can often identify which program fits fastest given your specific situation.

Monitoring Teriparatide Therapy

Once Highmark approves Forteo and therapy begins, monitoring follows a defined schedule to ensure both safety and efficacy.

Serum calcium should be checked within 3-6 months of starting therapy. Teriparatide can cause transient hypercalcemia in 2-3% of patients per the prescribing label; doses above 20 mcg are not approved and increase that risk. FDA teriparatide prescribing information

A repeat DEXA at 12-18 months provides the primary efficacy endpoint. The key Neer 2001 trial showed lumbar spine BMD increased by a mean of 9.7% at 18 months with 20 mcg teriparatide versus a 2.4% loss in the placebo group. Neer RM et al., NEJM 2001 Providing this interval DEXA data to Highmark at the 6-month renewal point demonstrates treatment response and supports continued PA approval.

At the conclusion of 24 months, transition to an antiresorptive agent is essential. Without sequential antiresorptive therapy, bone mineral density gains from teriparatide are lost within 12-18 months. The 2020 AACE guidelines specify denosumab or a bisphosphonate as preferred sequential agents. Camacho PM et al., Endocrine Practice 2020