Does Presbyterian Healthcare Services Cover Forteo?

How Presbyterian Healthcare Services Classifies Forteo on Its Formulary

Presbyterian Healthcare Services, one of the largest not-for-profit health systems in New Mexico, administers both commercial and Medicaid managed-care plans through Presbyterian Health Plan. On most Presbyterian formularies, Forteo (teriparatide) is classified as a specialty medication and placed on a non-preferred brand or specialty tier. This tier placement directly affects the copay or coinsurance a member pays at the pharmacy.

Specialty tier drugs across the U.S. insurance market carry median copays between $75 and $150 per fill for preferred agents, but non-preferred specialty biologics can push coinsurance to 25%, 33% of the drug's cost [1]. With Forteo's average wholesale price near $4,100 for a 28-day pen supply, a 25% coinsurance rate translates to roughly $1,025 before any manufacturer offset or out-of-pocket maximum kicks in. Presbyterian plans that use flat copays for specialty drugs tend to cap the per-fill amount between $150 and $500, though plan documents should be verified each benefit year.

The 2020 Endocrine Society Clinical Practice Guideline on pharmacological management of osteoporosis states that anabolic agents such as teriparatide are recommended for patients at "very high fracture risk," defined as those with recent fractures, T-scores below −3.0, or high FRAX probability scores [2]. Presbyterian's prior authorization criteria broadly mirror this guideline language.

Prior Authorization Requirements for Forteo Under Presbyterian

Presbyterian Health Plan requires prior authorization before dispensing Forteo. The request is typically reviewed by the plan's pharmacy benefit team against a set of medical necessity criteria. Getting the authorization approved on the first attempt depends heavily on how well the prescriber documents the clinical rationale.

Standard criteria that Presbyterian and similar managed-care plans apply include a confirmed diagnosis of osteoporosis (DXA T-score ≤ −2.5 at the spine or hip, or a documented fragility fracture), documented failure or intolerance of at least one oral bisphosphonate such as alendronate or risedronate, and absence of contraindications including hypercalcemia, Paget's disease of bone, or unexplained elevations in alkaline phosphatase [3]. The prescriber must also confirm the patient has not previously completed a full 24-month course, since the FDA label restricts lifetime teriparatide exposure to 24 months based on the original osteosarcoma signal in Fischer 344 rats [4].

Prior authorization decisions are usually returned within 72 hours for standard requests and within 24 hours for urgent requests. If a denial is issued, the plan must provide a written explanation, and the prescriber or member can file an appeal. A peer-to-peer review with a Presbyterian medical director is often the fastest path to reversal.

Step Therapy: Which Drugs Must Be Tried First?

Most Presbyterian plans enforce step therapy before authorizing Forteo. Step therapy is cost-containment logic requiring that a less expensive drug in the same therapeutic class be tried and failed before the plan will pay for a costlier alternative. For osteoporosis, this means an oral bisphosphonate is almost always the first-line requirement.

Generic alendronate 70 mg weekly costs approximately $4, $15 per month, making it roughly 300 times cheaper than branded Forteo on a per-month basis [5]. Presbyterian's step therapy protocol typically requires a minimum 12-month trial of alendronate or risedronate, documented adherence, and either a new fracture during therapy or a continued decline in bone mineral density on a follow-up DXA scan.

Some clinicians argue that step therapy delays necessary anabolic treatment. Dr. Felicia Cosman, then-professor of medicine at Columbia University and lead author of the 2020 Endocrine Society guideline, wrote: "In patients at very high fracture risk, starting with an anabolic agent rather than an antiresorptive may reduce fracture incidence more effectively" [2]. The VERO trial (N=1,360) demonstrated this concept directly: teriparatide reduced new vertebral fractures by 56% compared with risedronate over 24 months (relative risk 0.44 to 95% CI 0.29, 0.68, P<0.001) [6].

If a patient has already fractured on bisphosphonate therapy, the prescriber should document this clearly, as it usually satisfies step therapy requirements immediately and eliminates further waiting.

Expected Out-of-Pocket Costs With Presbyterian Coverage

Even after prior authorization approval, the out-of-pocket cost of Forteo under a Presbyterian plan depends on the specific benefit design, which varies between commercial HMO, PPO, and Centennial Care (Medicaid) products.

For commercial Presbyterian members, expect one of two copay structures. Plans using flat specialty copays typically charge $100, $500 per 28-day fill. Plans using percentage-based coinsurance may charge 20%, 33% of the negotiated drug cost, potentially exceeding $800 per fill before the annual out-of-pocket maximum is reached. Once a member hits the plan's annual out-of-pocket cap (often $4,000, $8,550 for individual coverage on ACA-compliant plans), further Forteo fills would cost $0.

For Centennial Care (New Mexico Medicaid managed care) members enrolled through Presbyterian, specialty drug copays are capped at nominal amounts, often $0, $3.40 per prescription, in accordance with federal Medicaid cost-sharing limits [7]. Medicaid members face far lower cost barriers, though the prior authorization process still applies.

Eli Lilly's Forteo Savings Card can reduce commercially insured copays to as low as $4 per month for eligible patients, with an annual benefit cap (often around $7,200 per year) [8]. This card cannot be used with Medicare, Medicaid, or other government-funded insurance.

How to Improve Your Chances of Getting Forteo Approved

A denied prior authorization is not the end of the road. Several strategies can improve approval odds.

First, have the prescriber submit a detailed letter of medical necessity. This letter should include the patient's DXA results with exact T-scores, fracture history with dates and anatomical sites, documentation of bisphosphonate trial duration and outcome, lab results ruling out contraindications (serum calcium, alkaline phosphatase, 25-hydroxyvitamin D), and a FRAX 10-year fracture probability calculation. The National Osteoporosis Foundation (now Bone Health & Osteoporosis Foundation) recommends pharmacologic treatment when the FRAX 10-year probability of hip fracture reaches ≥3% or major osteoporotic fracture reaches ≥20% [9].

Second, if the initial request is denied, file a formal appeal within 60 days. Request a peer-to-peer phone call between the prescribing physician and the plan's medical director. During this call, the prescriber can explain why the patient meets "very high risk" criteria and why continued antiresorptive therapy alone is insufficient.

Third, explore the Forteo manufacturer copay card or Lilly Cares patient assistance program for uninsured or underinsured patients. A 2019 analysis published in the Journal of Managed Care & Specialty Pharmacy found that manufacturer copay assistance programs reduced patient abandonment of specialty medications by 59% [10].

Fourth, consider whether biosimilar teriparatide is available. The FDA approved the first teriparatide biosimilar (Terrosa, marketed by Pfenex/Alvogen) in certain markets. If Presbyterian's formulary includes a biosimilar at a preferred tier, switching may cut costs significantly.

Medicare Advantage Plans Through Presbyterian

Presbyterian offers Medicare Advantage (Part C) plans in New Mexico. Coverage of Forteo under these plans follows Medicare Part D pharmacy benefit rules rather than commercial plan formulary logic. Under Part D, Forteo is typically placed on Tier 5 (specialty) and subject to 25%, 33% coinsurance during the initial coverage phase [11].

In 2025, Medicare Part D underwent structural changes through the Inflation Reduction Act. The annual out-of-pocket cap for Part D was reduced to $2,000 starting January 1, 2025 [12]. This means that Presbyterian Medicare Advantage members with Part D coverage who fill Forteo prescriptions will have their total annual pharmacy out-of-pocket spending capped at $2,000, regardless of how high coinsurance percentages might be per fill. A $2,000 cap over 12 months of Forteo use works out to approximately $167 per month, a significant reduction from prior years.

Medicare members should also verify whether their Presbyterian Medicare Advantage plan requires prior authorization for Forteo, as most do. The criteria mirror commercial plans but may reference Medicare's local coverage determination (LCD) for teriparatide if one exists in the Novitas Solutions jurisdiction covering New Mexico.

What Happens if Presbyterian Denies Forteo Coverage

If both the initial request and internal appeal are denied, members have additional options. Presbyterian must allow an external review by an independent review organization (IRO) if the internal appeal is exhausted. For Centennial Care members, the New Mexico Human Services Department oversees a fair hearing process.

The American Association of Clinical Endocrinology (AACE) 2020 guideline for postmenopausal osteoporosis offers supporting language for appeals. The guideline states: "Anabolic therapy should be considered as initial therapy for patients at very high fracture risk, particularly those with recent fractures" [13]. Including this direct guideline citation in an appeal letter strengthens the argument for medical necessity.

Another alternative: ask the prescriber whether denosumab (Prolia) or romosozumab (Evenity) might be appropriate. Denosumab is a biologic antiresorptive given as a 60 mg subcutaneous injection every 6 months and may sit on a different (sometimes more favorable) formulary tier. Romosozumab is a sclerostin inhibitor with anabolic properties and a 12-month treatment course. The ARCH trial (N=4,093) showed romosozumab followed by alendronate reduced clinical fracture risk by 27% compared with alendronate alone at 24 months [14]. However, romosozumab also requires prior authorization and carries its own cost challenges.

Generic Teriparatide and Biosimilar Availability

Branded Forteo's original patent expired in 2018, and generic teriparatide products have entered the market. Teva's generic teriparatide and the biosimilar pathway product from Alvogen/Pfenex offer potential cost savings. If Presbyterian's formulary lists a generic or biosimilar teriparatide at a preferred tier, the prior authorization process may be simpler and copays substantially lower.

A 2021 study in Osteoporosis International found that generic teriparatide availability reduced payer costs by an average of 30%, 50% compared with branded Forteo, depending on the market [15]. Patients should ask their prescriber and Presbyterian's pharmacy benefit team whether a generic or biosimilar option is currently on the formulary and whether it carries different prior authorization requirements.

The clinical efficacy of biosimilar teriparatide is considered equivalent. The FDA requires biosimilars to demonstrate no clinically meaningful differences from the reference product in pharmacokinetics, pharmacodynamics, safety, and efficacy [16].

Navigating Presbyterian's Pharmacy Benefit Team

Presbyterian Health Plan members can contact the pharmacy benefit team directly to verify Forteo's formulary status and prior authorization requirements for their specific plan. The member services number is printed on the back of the insurance card, and the pharmacy team can confirm tier placement, step therapy requirements, and expected copay amounts.

Prescribers can submit prior authorization requests through Presbyterian's online provider portal or by fax using the plan's standard prior authorization form. Turnaround time is typically 48 to 72 hours for non-urgent requests. For patients who need Forteo started quickly (such as those with acute vertebral fractures), the prescriber can request an expedited review, which must be completed within 24 hours under New Mexico insurance regulations.

Patients should also check whether their plan offers a specialty pharmacy network. Presbyterian often requires specialty drugs like Forteo to be dispensed through a designated specialty pharmacy (such as AllianceRx Walgreens Prime or a Presbyterian-affiliated specialty pharmacy), rather than a retail pharmacy. Specialty pharmacies may provide nurse support, refill coordination, and copay assistance navigation as part of the dispensing service.

The 24-month lifetime treatment limit for teriparatide means that every month of delay in obtaining authorization is a month of potential bone-building therapy lost. Starting the prior authorization process early, ideally at the same visit where the prescriber decides to initiate Forteo, prevents gaps in treatment.