Does Horizon Blue Cross Blue Shield of New Jersey Cover Forteo?

What Is Forteo and Why Does Its Cost Make Coverage So Important?

Forteo is a synthetic form of human parathyroid hormone (PTH 1-34) that stimulates new bone formation rather than simply slowing bone loss. The FDA first approved teriparatide in November 2002 for postmenopausal osteoporosis, osteoporosis in men, and glucocorticoid-induced osteoporosis [1]. Because it is an anabolic agent, it occupies a different pharmacological class from antiresorptives like bisphosphonates or denosumab.

The list price without insurance runs close to $3,000 per month. Over a full 24-month course, that is roughly $72,000 out of pocket. Coverage decisions therefore carry significant clinical consequence. Patients who cannot afford Forteo sometimes delay treatment or accept a subtherapeutic alternative, which may translate directly into fracture risk.

Horizon BCBS NJ is the largest health insurer in New Jersey, serving approximately 3.8 million members across commercial, Medicare Advantage, and Medicaid lines of business [2]. The insurer maintains its own pharmacy formulary that is updated quarterly, so coverage conditions can shift. Any information here reflects formulary structures current as of early 2025 and should be verified against the member's specific Evidence of Coverage document.

The key SOTI (Fracture Prevention Trial) studied 1,637 postmenopausal women with prior vertebral fractures and found teriparatide 20 mcg/day reduced the risk of new vertebral fractures by 65% and nonvertebral fragility fractures by 53% compared with placebo at a median of 19 months [3]. The American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology 2020 guidelines designate teriparatide as a first-line option specifically for patients at very high fracture risk, defined by a T-score at or below -3.0, prior fragility fracture, or very high FRAX probability [4].

How Does Horizon BCBS NJ Classify Forteo on Its Formulary?

Forteo sits on the specialty tier of the Horizon BCBS NJ formulary, which carries the highest cost-sharing level. Specialty tiers exist because these agents typically cost more than $600 per month and often require special handling, storage, or administration.

On most Horizon commercial plans, specialty-tier cost-sharing means a member pays either a fixed copay (often $150 to $300 per fill after deductible) or a coinsurance percentage (often 25% to 33%) depending on the specific plan design. The Explanation of Benefits document or the Horizon member portal at horizonblue.com will show the exact tier assignment for a given plan. Members enrolled in Horizon Medicare Advantage plans face slightly different cost-sharing structures governed by CMS Part D regulations [5].

Generic teriparatide (approved by the FDA in 2022) and the biosimilar Bonsity may appear on a lower tier on some Horizon formularies, reducing out-of-pocket cost substantially. Physicians writing "dispense as written" prescriptions should be aware this may result in specialty-tier cost-sharing even when a lower-cost equivalent is available.

The FDA's Orange Book lists teriparatide with multiple approved generics as of 2024 [6]. Horizon's Pharmacy and Therapeutics Committee typically places generics one tier below the brand, so it is worth confirming the tier of the specific product being prescribed.

What Prior Authorization Criteria Does Horizon BCBS NJ Apply to Forteo?

Prior authorization (PA) is required for Forteo on virtually every Horizon BCBS NJ plan. The PA criteria Horizon applies align closely with both FDA labeling and AACE guidelines, though the payer adds its own utilization-management layer.

Typical criteria include all of the following:

1. A diagnosis of osteoporosis confirmed by dual-energy X-ray absorptiometry (DXA) showing a T-score at or below -2.5 at the lumbar spine, femoral neck, or total hip, OR a history of low-trauma (fragility) fracture.
2. Step therapy: documentation that the patient has tried and either failed or cannot tolerate at least one antiresorptive agent (most commonly alendronate 70 mg weekly or risedronate 35 mg weekly for a minimum of 6 to 12 months).
3. Contraindication exceptions: patients with esophageal disorders, severe renal impairment (creatinine clearance <35 mL/min), or documented intolerance to bisphosphonates may bypass step therapy.
4. Prescriber qualification: the prescribing physician must typically be an endocrinologist, rheumatologist, or other specialist, or the prescription must include supporting documentation from a specialist consultation.
5. Absence of absolute contraindications per FDA labeling, including Paget's disease of bone, prior skeletal radiation, or unexplained elevations in alkaline phosphatase [1].

The FDA black box warning regarding osteosarcoma risk (observed in rat studies at doses 3 to 60 times the human dose) is a required disclosure but has not been confirmed in human populations across more than 20 years of post-marketing surveillance [7]. Horizon's PA criteria do not require osteosarcoma screening, consistent with the 2022 FDA label update that removed the black box warning for osteosarcoma following the post-marketing CORE study data [1].

What Is the Step Therapy Process and How Long Does It Take?

Step therapy requires documented prior use of a bisphosphonate before Forteo can be approved. The clinical rationale is pharmacoeconomic: alendronate costs roughly $10 to $30 per month (generic), while teriparatide costs roughly 100 times more. The Fracture Intervention Trial (FIT) demonstrated that alendronate reduced vertebral fracture risk by 47% in women with existing vertebral fractures over 3 years (N=2,027) [8], establishing bisphosphonates as an appropriate first-line choice for many patients.

Patients at very high fracture risk, however, should not necessarily follow this sequence. The AACE 2020 guidelines state: "For patients at very high risk of fracture, anabolic therapy should be considered as initial treatment rather than requiring prior antiresorptive failure." [4] This creates a clinical and administrative tension: the guideline recommends anabolics first, but the payer often requires antiresorptive failure first.

Physicians can document "inadequate response" if a patient sustained a new fracture while on a bisphosphonate, or document medical contraindication to avoid the step entirely. Processing time for a PA decision at Horizon typically runs 3 to 5 business days for standard review or 24 to 72 hours for urgent review when a clinician certifies clinical urgency.

Step therapy exemption laws vary by state. New Jersey's enacted step therapy reform legislation (N.J.S.A. 26:2SS-1 et seq.) requires insurers to grant exceptions when a required step therapy drug is contraindicated, has already failed, or the patient is stable on the requested drug [9]. Physicians should reference this statute explicitly in PA appeal letters when Horizon denies Forteo due to step therapy.

How Does a Physician Submit a Prior Authorization for Forteo Through Horizon?

The PA submission process at Horizon BCBS NJ can proceed through three channels: the Horizon NaviNet web portal, a fax-based PA request form (available at horizonblue.com/providers), or through a specialty pharmacy's hub service (e.g., the Lilly Cares patient support program for branded Forteo).

Required documentation typically includes:

• The completed Horizon PA form specifying the drug, dose, and diagnosis code (ICD-10 M81.0 for postmenopausal osteoporosis, M80.00 for osteoporosis with current pathological fracture, or M81.6 for localized osteoporosis).
• DXA report showing T-score at or below -2.5, or documentation of prior fragility fracture.
• Pharmacy records or prescriber attestation documenting bisphosphonate trial duration and reason for discontinuation or inadequacy.
• Relevant labs: serum calcium, 25-hydroxyvitamin D, creatinine, and alkaline phosphatase are commonly requested.

A 2021 analysis in the Journal of Managed Care and Specialty Pharmacy found that specialty drug PA processes average 5.8 days from submission to determination, with 26% of initial requests denied and requiring appeal [10]. Physicians who pre-populate all required fields and attach DXA reports at initial submission reduce denial rates substantially.

What Happens If Horizon Denies the Prior Authorization?

An initial denial is not the end of the road. Horizon must, under New Jersey law and ACA regulations, provide a written denial with the clinical rationale and inform the member of the right to appeal [9].

The appeals process has three stages: internal appeal, external independent review, and, if necessary, state regulatory complaint to the New Jersey Department of Banking and Insurance (DOBI). At the internal appeal stage, the physician should submit a peer-to-peer review request, which allows a direct phone conversation with the Horizon medical director reviewing the case. Published data suggest peer-to-peer reviews reverse denial decisions in approximately 30% to 50% of cases for specialty medications when the prescriber participates directly.

For the external appeal, an independent review organization (IRO) evaluates the case. Under New Jersey's external review statute, the IRO decision is binding on the insurer [9]. If the IRO determines Forteo is medically necessary based on the clinical record, Horizon must cover it regardless of its formulary criteria.

Patients facing denial while awaiting appeal may access Lilly's Forteo Savings Program, which offers the drug at no cost for eligible uninsured or underinsured patients, or the Lilly Cares Foundation program for lower-income patients [11]. Generic teriparatide through a GoodRx discount card at some New Jersey pharmacies runs approximately $800 to $1,200 per month, still substantial but lower than the list price.

What Does the Clinical Evidence Say About When Forteo Is the Right Choice?

The AACE 2020 Osteoporosis Clinical Practice Guidelines stratify fracture risk into high and very high categories and match treatment intensity to risk level [4]. The FDA-approved indications for teriparatide are [1]:

• Postmenopausal women with osteoporosis at high fracture risk.
• Men with primary or hypogonadal osteoporosis at high fracture risk.
• Men and women with glucocorticoid-induced osteoporosis at high fracture risk.

The SOTI trial (N=1,637) found a 65% relative risk reduction in new vertebral fractures (absolute risk reduction: 9.3 percentage points) at 19 months [3]. The nonvertebral fracture reduction of 53% was also statistically significant (P<0.001) [3].

The DATA (Denosumab And Teriparatide Administration) trial (N=94) compared teriparatide alone, denosumab alone, and the combination, finding that combination therapy produced the largest gains in hip bone mineral density (BMD) at 12 months: 4.9% for combination vs. 2.5% for teriparatide alone [12]. Sequential therapy, moving from teriparatide to an antiresorptive after 24 months, is essential because BMD gains are partially lost without a follow-on agent. The AACE guideline specifies: "Following anabolic therapy, antiresorptive treatment should be initiated to maintain bone mineral density gains." [4]

Bone turnover markers, specifically serum P1NP (procollagen type 1 N-terminal propeptide), rise within 1 month of teriparatide initiation and can serve as an early efficacy indicator. A P1NP increase above 10 mcg/L from baseline at 1 to 3 months is associated with a favorable BMD response according to data from the EuroSCOPE registry [13]. Horizon's PA criteria do not currently require P1NP monitoring, but clinicians may use this to document treatment response during the coverage period.

Are There Alternatives to Forteo That Horizon Covers More Easily?

Several anabolic and antiresorptive alternatives exist, and some carry lower PA hurdles on the Horizon formulary.

Romosozumab (Evenity, 210 mg subcutaneous monthly for 12 months) is another anabolic agent approved by the FDA in April 2019 [14]. It carries a black box warning for cardiovascular risk and is generally reserved for patients without prior stroke or myocardial infarction. Horizon applies similar PA criteria to romosozumab as to Forteo.

Abaloparatide (Tymlos, 80 mcg/day subcutaneous) was FDA-approved in April 2017 [15]. The ACTIVE trial (N=2,463) showed abaloparatide reduced new vertebral fractures by 86% at 18 months vs. placebo [15]. Horizon may place abaloparatide on a similar specialty tier.

Bisphosphonates remain the most formulary-accessible first-line option. Alendronate 70 mg weekly (generic) is typically Tier 1 or Tier 2 on Horizon formularies, with a monthly cost of under $30. Zoledronic acid (Reclast) 5 mg IV annually is covered under the medical benefit rather than pharmacy benefit and may involve different cost-sharing rules under Horizon's medical policy.

Denosumab (Prolia, 60 mg subcutaneous every 6 months) is FDA-approved for postmenopausal osteoporosis and similarly requires PA, but its PA criteria at Horizon typically do not require prior bisphosphonate failure in the same way Forteo does for certain high-risk patient profiles.

How Does Horizon Handle Forteo Under Medicare Advantage Plans?

Horizon offers Medicare Advantage plans in New Jersey, including HorizonCareBlue and Horizon Medicare Blue. Forteo under these plans falls under Part D pharmacy benefits and is subject to CMS formulary regulations rather than purely commercial insurance rules.

Under CMS Part D rules, plans must cover all or substantially all drugs in six protected classes: antidepressants, antipsychotics, anticonvulsants, antiretrovirals, immunosuppressants, and antineoplastics [5]. Osteoporosis drugs including teriparatide are not in a protected class, so Part D plans retain formulary flexibility.

The Medicare Extra Help (Low Income Subsidy) program can reduce specialty-tier cost-sharing to a nominal copay (approximately $11 per month in 2025) for qualifying beneficiaries [5]. Physicians treating Medicare patients who face high Forteo cost-sharing should screen for Extra Help eligibility. Income thresholds for full Extra Help are 100% of the federal poverty level (FPL), with partial subsidies available up to 150% FPL.

The Medicare Coverage Gap (donut hole) was effectively eliminated for most drugs as of January 1, 2024, under the Inflation Reduction Act, which caps annual out-of-pocket drug spending at $2,000 for Part D enrollees beginning in 2025 [5]. This cap may substantially reduce total annual cost for Medicare Advantage members on Forteo compared to prior years.

What Patient Assistance Programs Exist if Coverage Is Denied or Cost-Sharing Is Prohibitive?

The following framework helps clinicians match patients to the right financial assistance pathway based on insurance status and income:

Step 1: Confirm formulary tier and exact cost-sharing. Pull the member's specific Horizon plan formulary at horizonblue.com or call the Horizon pharmacy line (1-800-355-4728). Confirm whether the prescription is for branded Forteo or generic teriparatide, as tier placement differs.

Step 2: Submit PA with complete documentation. Attach DXA report, fracture history, bisphosphonate trial documentation, and relevant labs in the initial submission to minimize denial probability.

Step 3: If denied, request peer-to-peer review within 10 business days. The treating physician or specialist should make this call directly. Reference the AACE 2020 guideline criteria for very-high-risk patients and the New Jersey step therapy exemption statute [4][9].

Step 4: If cost-sharing remains high after approval, apply to Lilly Cares. Commercial patients with insurance may use the Lilly Forteo Savings Card, reducing out-of-pocket cost to as low as $0 per month for eligible patients (income and insurance restrictions apply) [11].

Step 5: For Medicare patients, screen for Extra Help. File a Social Security Administration form SSA-1020 or apply through the Social Security Administration website. Approval can reduce specialty-tier copays to approximately $11 monthly [5].

Step 6: Consider generic teriparatide or Bonsity. If the brand is denied or cost-prohibitive, generic teriparatide FDA-approved equivalents offer the same 20 mcg/day dose at potentially lower cost and a lower formulary tier.

What Are the Clinical Monitoring Requirements During Forteo Treatment?

Bone density monitoring by DXA should occur every 1 to 2 years during teriparatide therapy, consistent with AACE recommendations [4]. Serum calcium should be checked 4 to 6 hours after the first dose, as teriparatide transiently increases calcium and may cause hypercalcemia in susceptible patients [1].

Vitamin D sufficiency (25-hydroxyvitamin D above 30 ng/mL) is a prerequisite for optimal response. A 2011 study in the Journal of Clinical Endocrinology and Metabolism (N=173) found that teriparatide produced significantly lower lumbar spine BMD gains in vitamin D-deficient patients compared to sufficient patients at 18 months [16]. Repleting vitamin D to above 30 ng/mL before initiating teriparatide is standard clinical practice.

Alkaline phosphatase should be checked at baseline; unexplained elevation may suggest Paget's disease, which is an absolute contraindication per FDA labeling [1]. Renal function (eGFR) should also be confirmed, as severe renal impairment (eGFR <30 mL/min) is listed as a precaution.

After 24 months, teriparatide must be stopped. The prescribing information specifies a lifetime maximum of 24 months [1]. Transition to an antiresorptive agent (typically denosumab or zoledronic acid) within 1 to 3 months of stopping teriparatide preserves the BMD gains made during anabolic therapy, per the AACE 2020 guidelines [4].