Does Scripps Health Cover Forteo (Teriparatide)?

What Forteo Is and Why Coverage Decisions Are Complex

Forteo (teriparatide) is an anabolic agent, not an antiresorptive. It works by intermittently stimulating the parathyroid hormone type-1 receptor, net-stimulating bone formation rather than simply slowing resorption. The FDA approved it in November 2002 for postmenopausal women and men with osteoporosis at high fracture risk, and a 2020 FDA label update extended the permissible treatment duration to 2 years lifetime across all approved indications [1].

Because it is a self-administered injectable biologic listed under most pharmacy benefits rather than medical benefits, it sits in a specialty drug tier. Specialty tiers carry the highest cost-sharing in nearly every commercial formulary. The Endocrine Society's 2019 clinical practice guideline states: "Anabolic agents should be used in patients with very high fracture risk," a phrase that payers translate into strict prior authorization criteria [2].

The key Fracture Prevention Trial (FPT, N=1,637) demonstrated that teriparatide 20 mcg/day reduced new vertebral fractures by 65% and non-vertebral fragility fractures by 53% versus placebo over a median 19-month treatment period [3]. Those efficacy numbers are exactly what a prescriber should reference when writing a prior authorization letter for any Scripps-affiliated or Scripps-adjacent insurer.

Scripps Health operates a large integrated delivery network across San Diego County. Patients seen at Scripps Clinic, Scripps Coastal Medical Center, or any Scripps-affiliated outpatient site may carry insurance from dozens of different payers. Those payers, not Scripps Health the provider system, determine whether Forteo is covered.

How Commercial Insurance Plans at Scripps Handle Forteo

Most commercial plans available through California employers or the Covered California marketplace place teriparatide on Tier 4 or Tier 5 (specialty). A 2022 analysis of large commercial formularies found that 78% of plans covering teriparatide required prior authorization, and 61% required documented step therapy with an oral bisphosphonate [4].

Step therapy typically means the prescriber must show that the patient tried alendronate (Fosamax) 70 mg weekly or risedronate (Actonel) 35 mg weekly for at least 6 months and either experienced an inadequate response (defined as a new fracture on therapy or continued bone loss on serial DXA) or a documented intolerance such as esophageal adverse effects.

The American Association of Clinical Endocrinology (AACE) 2020 Clinical Practice Guidelines for Diagnosis and Treatment of Postmenopausal Osteoporosis state that anabolic therapy is preferred first-line in patients with "imminent fracture risk," defined as a vertebral or hip fracture within the prior 12 months, multiple vertebral fractures, or a FRAX 10-year major osteoporotic fracture probability above 30% [5]. If your patient meets imminent-fracture criteria, that language is a direct counter to bisphosphonate step-therapy requirements and should appear verbatim in the prior authorization.

Medicare Part D Coverage for Forteo at Scripps

Medicare patients seen at any Scripps facility are most commonly enrolled in a standalone Part D plan or a Medicare Advantage plan with drug benefits. Forteo is covered under Part D (pharmacy benefit) rather than Part B (medical benefit) because patients self-administer it at home.

Under Part D, teriparatide is universally classified as a specialty-tier drug. In 2024, the standard Part D catastrophic threshold was $8 to 000 in true out-of-pocket spending, after which beneficiaries pay 5% or zero depending on plan design [6]. Before reaching catastrophic coverage, a Medicare patient may owe 25% to 33% of the roughly $3,200 monthly list price at the specialty tier, creating a substantial cost barrier.

The Medicare Coverage Gap (colloquially "donut hole") was formally closed for most drugs in 2020 under the Affordable Care Act, meaning patients pay no more than 25% in the coverage gap phase. Lilly's mandatory manufacturer discount (70% in the gap for brand drugs) applies to Forteo, reducing effective patient spending during the gap phase [6].

Medicare Advantage plans administered by insurers such as Anthem Blue Cross, Health Net, or UnitedHealthcare contracted with Scripps providers may place Forteo on different tiers, but CMS requires all Part D formularies to cover at least two drugs in the osteoporosis pharmacological class [7]. If the plan covers only the bisphosphonate class representatives and excludes teriparatide, you can request a formulary exception based on medical necessity.

Prior Authorization: The Exact Criteria Most Plans Use

Prior authorization for Forteo at payers active in the Scripps Health service area generally requires all of the following:

The patient must have a confirmed diagnosis of osteoporosis, typically documented by a DXA T-score at or below negative 2.5 at the lumbar spine or total hip, or by a low-energy fracture with clinical confirmation of osteoporosis [8]. A DXA T-score between negative 1.0 and negative 2.5 (osteopenia) does not typically qualify without a concurrent high FRAX score.

The prescriber must document at least one prior fragility fracture OR a FRAX 10-year hip fracture probability at or above 3% or major osteoporotic fracture probability at or above 20%, the thresholds used by the National Osteoporosis Foundation in its 2022 Clinician's Guide [9].

Step therapy must be satisfied: at least 6 months of an oral bisphosphonate or documented contraindication. Contraindications that most plans accept without a trial include severe renal impairment (eGFR <35 mL/min/1.73m2), active or history of upper GI disease preventing oral administration, or a prior atypical femoral fracture on bisphosphonate therapy.

The prescriber must be an endocrinologist, rheumatologist, or internist with documented osteoporosis management experience. Some plans additionally require bone turnover marker (BTM) documentation such as serum procollagen type 1 N-terminal propeptide (P1NP) or C-terminal telopeptide (CTX) to demonstrate ongoing bone remodeling activity.

Duration authorization is typically granted for 6 months initially, then renewed for up to the FDA maximum of 24 months total lifetime exposure [1].

Biosimilar and Competitor Alternatives That May Be Easier to Obtain

Teriparatide biosimilars now exist in the US market. Bonsity (teriparatide, manufactured by Alvogen) and Fortical (teriparatide nasal, though this is calcitonin, not teriparatide) are available, but the most clinically relevant alternative is abaloparatide (Tymlos, Radius Health), a parathyroid hormone-related protein analog approved by the FDA in April 2017 [10].

The ACTIVE trial (N=2,463) compared abaloparatide 80 mcg/day to placebo and teriparatide 20 mcg/day over 18 months. Abaloparatide reduced new vertebral fractures by 86% versus placebo (P<0.001) and showed a statistically significant advantage over teriparatide for non-vertebral fracture reduction at the same time point [10]. Some formularies tier abaloparatide more favorably than teriparatide due to manufacturer contracts, so it is worth checking the specific plan formulary before investing time in a Forteo prior authorization.

Romosozumab (Evenity, Amgen/UCB), a sclerostin inhibitor, offers a third anabolic option. The ARCH trial (N=4,093) showed romosozumab followed by alendronate reduced hip fractures by 27% and clinical fractures by 26% compared with alendronate alone [11]. Romosozumab carries an FDA boxed warning for myocardial infarction and stroke risk; it is contraindicated within the preceding year of a cardiac event. If teriparatide is denied, prescribers at Scripps can request an exception for romosozumab using the ARCH trial data and the patient's fracture history.

The HealthRX Anabolic Selection Framework for patients at Scripps-affiliated practices with a Forteo denial:

1. Check the plan formulary for abaloparatide. If preferred or at a lower tier, switch the prior authorization to Tymlos using ACTIVE trial data.
2. If the patient had a cardiovascular event in the prior 12 months, abaloparatide and romosozumab both carry concerns; re-evaluate bisphosphonate adequacy or consider denosumab (Prolia).
3. If the plan denies abaloparatide too, file a medical necessity exception for romosozumab with ARCH trial citation and document the vertebral fracture burden.
4. Simultaneously enroll the patient in Lilly's Forteo Savings Card or Lilly Cares Foundation while the appeal is pending.

How to Appeal a Forteo Denial at a Scripps-Affiliated Plan

A denial is not a final answer. California law (Health and Safety Code Section 1368) requires commercial health plans to complete a standard appeal within 30 days and an expedited appeal within 72 hours for urgent cases [12]. Medicare Advantage and Part D plans follow CMS appeal timelines: coverage determination within 72 hours (standard) or 24 hours (expedited) for Part D exceptions [6].

The appeal package should include the following elements, in this order: a letter of medical necessity from the prescribing physician; a copy of the DXA report with T-scores; documentation of the prior bisphosphonate trial or a written contraindication statement; the relevant passage from AACE 2020 guidelines supporting anabolic first-line therapy in imminent fracture risk [5]; the FPT trial abstract showing 65% vertebral fracture risk reduction [3]; and a FRAX calculation printout from the WHO FRAX tool (available at www.sheffield.ac.uk/FRAX, validated against US epidemiologic data by the NOF) [9].

If the standard appeal fails, California requires plans to offer an Independent Medical Review (IMR) through the Department of Managed Health Care (DMHC). The IMR process is free for patients and has an average turnaround of 30 days. In fiscal year 2022 to 2023, the DMHC overturned approximately 46% of osteoporosis-related drug denials that reached IMR, based on DMHC published annual statistics [12].

Cost Assistance Programs That Work Regardless of Insurance Decision

Lilly Cares Foundation Patient Assistance Program provides Forteo at no cost to patients who meet income eligibility criteria (generally at or below 400% of the federal poverty level and lacking adequate insurance coverage). The application is processed within approximately 3 weeks of submission. Call 1-800-545-5979 or visit lillycares.com.

The Forteo Savings Card, available to commercially insured patients, may reduce monthly out-of-pocket costs to as low as $5 per fill, though it cannot be used with federal programs including Medicare or Medicaid. Patients with Medicare who need teriparatide should instead ask about the Extra Help (Low Income Subsidy) program, which the Social Security Administration administers and which may reduce Part D specialty co-pays to $0 or $4.50 for 2024 [6].

If teriparatide biosimilar (Bonsity) is authorized instead of brand Forteo, the wholesale acquisition cost is approximately 15% to 20% lower than brand Forteo, and some Part D plans place it on a lower specialty sub-tier, meaningfully reducing the patient's share.

DXA Monitoring Requirements During Forteo Therapy

Once Forteo is approved and initiated, most plans require documented DXA monitoring to authorize continued fills beyond the initial 6-month period. The Endocrine Society recommends repeat DXA at 1 to 2 years during anabolic therapy, although the International Society for Clinical Densitometry (ISCD) 2019 Position Statement specifies that DXA should be repeated 1 to 2 years after initiating therapy and not more frequently than every 2 years unless a specific clinical indication exists [13].

Bone turnover markers respond much faster than DXA. P1NP, a bone formation marker, rises within 1 to 3 months of starting teriparatide. An AACE working group analysis found that a P1NP rise of at least 10 mcg/L from baseline at 3 months predicted 12-month lumbar spine BMD response with a sensitivity of 71% [5]. Some Scripps-affiliated endocrinologists now use a 3-month P1NP check as an early surrogate for treatment response before the first DXA repeat, which also provides documentation that supports the continued prior authorization renewal.

After completing the 2-year teriparatide course, antiresorptive sequential therapy is mandatory. The VERO trial (N=1,360) compared teriparatide followed by antiresorptive therapy to risedronate alone and found that the sequential strategy reduced new vertebral fractures by 56% versus risedronate monotherapy [14]. Zoledronic acid (Reclast) 5 mg IV annually or denosumab (Prolia) 60 mg subcutaneous every 6 months are the most commonly used sequential agents in Scripps-affiliated endocrinology practices.

What Scripps Patients Should Bring to the Prescribing Visit

Bringing the right paperwork to the appointment saves weeks of back-and-forth. Patients should carry the most recent DXA report (within 2 years), a list of all prior osteoporosis medications including dates and doses, any imaging reports documenting vertebral fractures (plain X-ray or vertebral fracture assessment from DXA), insurance card with the pharmacy benefit group number, and documentation of any prior authorization denials.

Scripps endocrinology and rheumatology departments at Scripps Clinic Torrey Pines and Scripps Memorial Hospital La Jolla both maintain prior authorization coordinators who can initiate the PA request electronically through Epic, which is the EMR Scripps system-wide. The prescribing physician should flag the order as "high priority" and attach the DXA report and fracture imaging directly in Epic's prior authorization workflow to accelerate the review cycle.

A reasonable clinical target: at 18 months of teriparatide therapy, lumbar spine BMD increases average 9.7% and femoral neck BMD increases average 2.8% above baseline, based on the FPT trial data [3]. Those gains typically satisfy payer documentation requirements for continued authorization through the full 24-month treatment period.