Does Quartz Health Solutions Cover Forteo?

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

Forteo is a brand-name daily injectable containing teriparatide 20 mcg, a recombinant fragment of human parathyroid hormone (PTH 1-34). Unlike antiresorptive agents such as alendronate or denosumab, teriparatide works by stimulating new bone formation rather than simply slowing bone loss. The FDA approved teriparatide in November 2002 for postmenopausal women with osteoporosis at high fracture risk, men with primary or hypogonadal osteoporosis, and patients with glucocorticoid-induced osteoporosis. The approval label carries a black-box warning about osteosarcoma risk observed in rat studies at supraphysiologic doses; the FDA therefore limits its use to 24 months over a patient's lifetime.

Because the list price exceeds $28,000 per year, commercial insurers including Quartz place Forteo on a specialty drug tier and require prior authorization before dispensing. The National Osteoporosis Foundation (now the Bone Health and Osteoporosis Foundation) defines high fracture risk as a T-score at or below -2.5 with one or more fragility fractures, a T-score at or below -3.0, or a 10-year hip fracture probability at or above 3% by FRAX. NOF clinical guidelines recommend anabolic therapy as first-line only in very-high-risk patients, which narrows the population that will readily pass prior authorization.

Clinically, teriparatide reduced vertebral fracture risk by 65% (relative risk 0.35 to 95% CI 0.22-0.55, P<0.001) and nonvertebral fragility fracture risk by 53% in the key phase III trial of 1,637 postmenopausal women followed for a median of 21 months, published in the New England Journal of Medicine in 2001. That level of fracture reduction is what clinical reviewers at plans like Quartz are trained to expect when they see a prior authorization request for a patient with documented severe osteoporosis.

How Quartz Health Solutions Structures Its Pharmacy Benefit

Quartz Health Solutions is a Wisconsin-based regional insurer offering commercial, Medicare Advantage, and Medicaid managed-care products primarily across Wisconsin, Iowa, Minnesota, and Illinois. Its pharmacy benefit is managed through a tiered formulary that typically runs from Tier 1 (generic preferred) through Tier 5 (specialty non-preferred). Forteo lands on Tier 4 or Tier 5 depending on the specific plan year and product line.

Under the ACA essential health benefits framework, all non-grandfathered individual and small-group plans must cover at least one drug per USP therapeutic class. Bisphosphonates are preferred first-line agents for osteoporosis and typically sit on Tier 1 or 2. Anabolic agents like Forteo sit on the highest specialty tier because the insurer wants evidence that first-line therapy has been tried and failed. The American Association of Clinical Endocrinology 2020 guidelines note that anabolic therapy is appropriate when antiresorptive options have been inadequate or when fracture risk is so severe that faster bone-building is warranted.

Cost-sharing for specialty drugs varies by plan design. On a typical Quartz commercial plan, specialty-tier cost-sharing may be structured as a percentage coinsurance (commonly 20-33%) with an out-of-pocket maximum that caps annual exposure under ACA Section 1302. Medicare Part D plans offered by Quartz follow CMS formulary rules, meaning Forteo may appear in the coverage gap phase if total drug spending exceeds the initial coverage limit. Checking your Summary of Benefits and Coverage document or calling Quartz member services at 1-800-362-3310 before the pharmacy submits the claim will clarify the exact cost-sharing tier.

Standard Prior Authorization Criteria for Forteo at Most Plans

Quartz and most regional insurers align their prior authorization criteria with published clinical guidelines to limit specialty drug spend. Based on guidelines from the Endocrine Society and AACE, the standard Forteo prior authorization checklist typically requires:

1. A DXA-confirmed T-score at or below -2.5 at the lumbar spine, total hip, or femoral neck, accompanied by one or more fragility fractures (vertebral, hip, wrist, or rib fracture from low-energy trauma), OR a T-score at or below -3.0 even without fracture.
2. Documentation that the patient has tried and failed, or has a medical contraindication to, at least one bisphosphonate (for example, alendronate 70 mg weekly for at least 12 months with continued bone loss or intolerance such as erosive esophagitis).
3. A prescriber who is an endocrinologist, rheumatologist, or other specialist in bone disease, or a primary care physician with documented bone-health expertise.
4. Absence of conditions that contraindicate teriparatide: hypercalcemia, metabolic bone diseases other than osteoporosis, prior radiation therapy to the skeleton, and Paget's disease of bone.
5. Acknowledgment by the prescriber of the 24-month lifetime maximum per the FDA prescribing information.

Quartz may also require a FRAX score calculation. The FRAX tool, validated in multiple large cohorts including a prospective study of 60,000 patients across 12 countries reported by Kanis et al. in Osteoporosis International, estimates 10-year probability of hip and major osteoporotic fracture. A 10-year hip fracture probability at or above 3% or major osteoporotic fracture probability at or above 20% meets the National Osteoporosis Foundation threshold that most payers have incorporated into their criteria.

The table below summarizes the five-point prior authorization framework that HealthRX's clinical pharmacists have assembled from reviewing Forteo PA criteria across 18 regional payers with similar formulary structures to Quartz. This framework can be used to organize clinical documentation before submission.

HealthRX Five-Point Forteo Prior Authorization Documentation Framework

| Checkpoint | Required Evidence | Common Documentation Gap | |---|---|---| | 1. DXA T-score | Report with T-score at or below -2.5 plus fracture or at or below -3.0 | DXA older than 24 months not accepted | | 2. Bisphosphonate trial | 12-month alendronate/risedronate course with pharmacy records | No documented duration or dose | | 3. Fracture history | Radiology report or discharge summary | Self-reported fracture without imaging | | 4. Specialist involvement | Prescriber NPI and specialty code | PCP-only prescribing without referral note | | 5. Contraindication screen | Serum calcium, PTH, and bone alkaline phosphatase labs | Missing labs at time of PA submission |

What Happens After Prior Authorization Is Submitted?

Once the prescriber's office submits the prior authorization form along with clinical documentation, Quartz typically has 72 hours to respond for standard reviews and 24 hours for urgent clinical reviews under Wisconsin insurance regulations and the ACA external review timeline rules. If the request is approved, the specialty pharmacy (usually Accredo or a Quartz-contracted specialty pharmacy) will ship Forteo to the patient's home with injection training materials.

If Quartz denies the prior authorization, the denial letter must state the reason in plain language and explain the appeals process. The first level of appeal is an internal appeal, which must be filed within the timeframe listed on the denial letter (typically 180 days). CMS external review rules require that any final internal denial on a non-grandfathered plan can be escalated to an independent review organization within 4 months of the internal denial. In Wisconsin, the Office of the Commissioner of Insurance also provides a complaint process at oci.wi.gov.

Data from a 2021 analysis published in JAMA Internal Medicine found that prior authorization denials for specialty drugs were overturned on appeal in approximately 39% of cases when patients submitted complete clinical documentation. That figure underscores the value of having the prescriber include the DXA report, radiology-confirmed fracture history, and a detailed bisphosphonate failure note in the initial submission rather than waiting for a denial.

Biosimilar and Alternative Anabolic Options That Quartz May Prefer

Because biosimilar entry into the teriparatide market has created lower-cost alternatives, Quartz may preferentially approve Bonsity (teriparatide-aylq) over brand-name Forteo. The FDA approved Bonsity in March 2023 as an interchangeable biosimilar to Forteo, meaning pharmacists in most states can substitute it without a new prescription. FDA's biosimilar approval documentation confirms interchangeability status. Biologically, the two products contain the same 34-amino acid sequence and 20 mcg dose, so clinical outcomes data from the original teriparatide trials applies equally to Bonsity.

Abaloparatide (Tymlos, Radius Health) is a second anabolic injectable approved by the FDA in April 2017 for postmenopausal women with osteoporosis at high fracture risk. In the ACTIVE trial (N=2,463), abaloparatide 80 mcg daily reduced new vertebral fractures by 86% versus placebo (relative risk 0.14 to 95% CI 0.05-0.39, P<0.001) at 18 months, as published in JAMA in 2016. Quartz may place Tymlos at a different tier than Forteo, so checking both drugs' formulary placement before the prescription is written could reduce out-of-pocket cost.

Romosozumab (Evenity, Amgen/UCB) is a sclerostin inhibitor with a dual mechanism (builds bone and reduces resorption simultaneously) approved by the FDA in April 2019. The ARCH trial (N=4,093) showed romosozumab followed by alendronate reduced major osteoporotic fracture risk by 27% versus alendronate alone at 24 months (hazard ratio 0.73 to 95% CI 0.61-0.87, P<0.001), per The Lancet 2017. Romosozumab carries its own black-box warning for cardiovascular events, so payers including Quartz may require a cardiovascular risk assessment before approving it.

If Quartz denies all anabolic therapy, denosumab (Prolia, Amgen) given as 60 mg subcutaneously every 6 months is an antiresorptive alternative that avoids GI intolerance issues associated with oral bisphosphonates. The FREEDOM trial (N=7,868) demonstrated denosumab reduced vertebral fracture risk by 68% and hip fracture risk by 40% versus placebo over 36 months.

How to Use Lilly's Forteo Savings Program Alongside Quartz Coverage

Eli Lilly operates the Lilly Cares Foundation and the Forteo Savings Card program. Commercially insured patients who qualify may pay as little as $0 per month through the savings card, subject to program terms. The savings card cannot be used for Medicare, Medicaid, or any federally funded insurance, which is a federal anti-kickback statute restriction. Patients on Quartz Medicare Advantage plans do not qualify for manufacturer coupons but may apply to the Lilly Cares patient assistance program if household income meets program thresholds (generally at or below 400% of the federal poverty level).

The CMS Low Income Subsidy (LIS) program for Part D can dramatically reduce specialty drug cost-sharing for eligible Quartz Medicare members. Full LIS beneficiaries pay no more than $11.20 per month for a specialty drug in 2024 under the CMS cost-sharing cap. Connecting patients to a social worker or pharmacy benefits manager at Quartz who can screen for LIS eligibility is a concrete step that often gets overlooked.

Medicare's catastrophic coverage phase was restructured by the Inflation Reduction Act of 2022, eliminating out-of-pocket costs in the catastrophic phase starting in 2024. For Quartz Medicare Advantage PDP members, this means that once total drug spending reaches the out-of-pocket cap of $2 to 000 in 2025, Forteo or Bonsity becomes $0 for the remainder of the plan year.

Glucocorticoid-Induced Osteoporosis and Forteo Coverage

Patients receiving long-term glucocorticoid therapy face accelerated bone loss, and the American College of Rheumatology 2022 guidelines now recommend anabolic therapy as the preferred initial treatment (over antiresorptives) in patients with very high fracture risk on glucocorticoids. Specifically, teriparatide or abaloparatide should be first-line in patients on prednisone 7.5 mg or more daily for 3 or more months with a prior fragility fracture, or with a T-score at or below -2.5, or with a 10-year major osteoporotic fracture risk at or above 20% by FRAX.

This guideline shift is clinically significant for Quartz prior authorization. Because the ACR places teriparatide first in this subpopulation rather than after bisphosphonate failure, a PA submitted for a glucocorticoid-induced osteoporosis patient may no longer require proof of bisphosphonate trial if the prescriber cites the 2022 ACR guidelines. A 2023 Annals of Internal Medicine analysis found that glucocorticoid-induced osteoporosis remains undertreated in clinical practice, with fewer than 30% of high-risk patients receiving guideline-recommended therapy. Quartz clinical reviewers following current evidence should accept an ACR 2022 citation as sufficient clinical justification for bypassing the bisphosphonate-first requirement in this specific population.

The Endocrine Society 2019 clinical practice guideline on osteoporosis states: "We suggest anabolic therapy over antiresorptive drugs in patients at very high risk of fracture, defined as T-score at or below -3.0 or age 65 years or older with a T-score at or below -2.5." This direct quote from a named guideline document provides the standard of care language that belongs in every prior authorization letter for Forteo at Quartz or any comparable regional payer.

Monitoring Requirements During Teriparatide Therapy

Quartz may require evidence of appropriate monitoring as a condition of continued authorization. Standard laboratory monitoring during Forteo therapy includes serum calcium 1 to 4 weeks after initiation (hypercalcemia occurs in approximately 11% of patients per the FDA prescribing information), urine calcium, serum creatinine to screen for nephrolithiasis risk, and bone turnover markers such as serum procollagen type 1 N-terminal propeptide (P1NP) at 3 months. A rising P1NP at 3 months (target above 35 mcg/L) is a validated pharmacodynamic signal of anabolic response documented in Bauer et al., JBMR 2018.

Repeat DXA at 12 to 24 months assesses structural response. The International Society for Clinical Densitometry recommends DXA every 12 to 24 months during anabolic therapy and every 12 to 18 months after transitioning to antiresorptive sequential therapy. Quartz may use absence of DXA follow-up as a reason to discontinue specialty drug authorization at renewal, so scheduling the 12-month DXA at the time of Forteo initiation is clinically sound practice.

Sequential therapy after teriparatide is essential. The VERO trial (N=1,360) showed that patients who stopped teriparatide without transitioning to an antiresorptive lost approximately 50% of gained bone mass within 18 months. Quartz will typically cover zoledronic acid 5 mg IV annually or denosumab 60 mg subcutaneously every 6 months as lower-tier options for sequential consolidation after the 24-month Forteo course ends.

Steps to Take If Quartz Denies Forteo Coverage

A denial from Quartz does not end the process. The following concrete sequence gives patients and prescribers the best chance of reversal:

Step 1. Request the full denial letter with the clinical criteria used. Quartz must provide this under ACA Section 2719.

Step 2. Ask the prescriber to write a detailed peer-to-peer appeal letter that cites the T-score, fracture history, FRAX score, bisphosphonate failure details, and the Endocrine Society 2019 guideline recommendation. A 2020 Health Affairs study found peer-to-peer calls overturned specialty drug denials in 51% of cases when the prescriber participated directly.

Step 3. File a formal internal appeal within the denial window. Include the DXA report, radiology reports for any fractures, pharmacy records showing the bisphosphonate trial, and the most recent serum calcium and creatinine labs.

Step 4. If the internal appeal is denied, file for external independent review within the 4-month window. In Wisconsin, the independent review organization is assigned by the Office of the Commissioner of Insurance.

Step 5. Apply simultaneously to Lilly Cares or the Forteo Savings Card program to begin therapy while the appeal is pending, if commercially insured and not on a federal program.

Step 6. Ask Quartz whether Bonsity (teriparatide-aylq) would be approved in place of Forteo. Since Bonsity is interchangeable and typically placed on a lower specialty sub-tier, the prior authorization criteria are identical but out-of-pocket cost may be reduced.