Does Security Health Plan Cover Forteo?

How Security Health Plan Classifies Forteo on Its Formulary

Security Health Plan, operated by Marshfield Clinic Health System in Wisconsin, places Forteo on its specialty medication tier. This classification means higher cost-sharing compared to generic or preferred brand medications, and it triggers mandatory prior authorization before dispensing.

Forteo carries an average wholesale price exceeding $4,100 for a 28-day supply pen [1]. Health plans categorize it as a high-cost specialty drug for this reason. Security Health Plan requires the prescribing provider to submit clinical documentation proving medical necessity before the pharmacy can fill the prescription. The plan's pharmacy and therapeutics committee reviews anabolic bone agents separately from oral antiresorptive therapies, placing teriparatide in a distinct coverage category from drugs like alendronate or risedronate.

Most Security Health Plan members hold either an HMO or POS product. Both product lines follow the same formulary structure for specialty injectables. The plan contracts with a designated specialty pharmacy network, and members must typically fill Forteo through that network rather than a retail pharmacy. Attempting to fill at a non-network pharmacy will result in a claim denial regardless of prior authorization status [2].

Prior Authorization Requirements for Forteo

The prior authorization process is the single largest barrier between a prescription and actual coverage. Security Health Plan requires documentation of a confirmed osteoporosis diagnosis with a DXA T-score of -2.5 or lower at the lumbar spine, femoral neck, or total hip [3].

Beyond the T-score threshold, the plan's criteria typically include several clinical checkpoints. The prescriber must confirm a diagnosis of osteoporosis (not osteopenia alone). A DXA scan performed within the past 24 months must be on file. The patient should have a documented history of fragility fracture or a FRAX 10-year major osteoporotic fracture probability exceeding 20% [4]. The prescriber must also attest that the patient has tried and failed, or has a documented contraindication to, at least one oral bisphosphonate.

Dr. Michael McClung, founding director of the Oregon Osteoporosis Center, has stated: "Anabolic agents like teriparatide should be considered as initial therapy in patients at very high fracture risk, rather than reserving them as second-line options after bisphosphonate failure" [5]. The 2020 Endocrine Society guidelines echo this position, recommending teriparatide as first-line therapy for patients with severe osteoporosis, defined as a T-score of -3.0 or lower, or multiple vertebral fractures [6].

Security Health Plan does allow exceptions to step therapy for patients who meet very-high-risk criteria. Providers should document the specific clinical rationale for bypassing bisphosphonate trial when submitting the prior authorization request.

Step Therapy: What You Must Try First

Step therapy is the requirement to try a less costly medication before the plan approves a more expensive one. For Forteo, Security Health Plan generally mandates a trial of oral bisphosphonate therapy lasting at least 12 months.

Acceptable first-step medications include alendronate (Fosamax), risedronate (Actonel), or ibandronate (Boniva). The plan considers a bisphosphonate "failed" if the patient experienced a new fragility fracture during therapy, showed continued bone density decline on follow-up DXA, or developed documented adverse effects such as esophageal ulceration or osteonecrosis of the jaw [7]. Gastrointestinal intolerance alone may not satisfy the step therapy requirement unless the prescriber documents specific symptoms and their severity.

Contraindications that bypass step therapy include esophageal disorders (achalasia, stricture, Barrett's esophagus), inability to remain upright for 30 minutes after dosing, chronic kidney disease with eGFR below 30 mL/min/1.73m², and hypocalcemia [8]. Patients with these conditions should have the specific contraindication clearly stated in the prior authorization submission rather than simply checking a "contraindication present" box.

The VERO trial (N=1,360) compared teriparatide directly against risedronate in patients with severe osteoporosis and found that teriparatide reduced new vertebral fractures by 56% (HR 0.44 to 95% CI 0.29 to 0.68, P<0.001) and clinical fractures by 52% over 24 months [9]. This trial provides strong evidence for providers arguing that anabolic therapy should precede, not follow, antiresorptive treatment in high-risk patients.

Expected Out-of-Pocket Costs After Approval

Once prior authorization is granted, the member's cost-sharing depends on their specific plan design. Security Health Plan offers multiple benefit tiers, and specialty medications like Forteo sit on the highest tier.

For members with a standard HMO plan, specialty tier copays typically range from $50 to $150 per 28-day supply. Some high-deductible health plan (HDHP) designs require the member to pay the full negotiated rate until the deductible is met, which can mean several hundred dollars per fill early in the plan year. After the annual out-of-pocket maximum is reached (typically $4,000 to $8,700 for individual coverage under ACA-compliant plans), the plan pays 100% of covered costs [10].

Eli Lilly operates the Lilly Cares Patient Assistance Program for commercially insured patients, which can reduce out-of-pocket costs to as little as $25 per month for eligible individuals. The Forteo Savings Card program is separate and applies only to commercially insured patients, not those on Medicare or Medicaid. Members should verify whether Security Health Plan allows manufacturer copay assistance to count toward their deductible and out-of-pocket maximum, as some plans exclude these payments from accumulator calculations [11].

The biosimilar teriparatide (Terrosa, manufactured by Gedeon Richter) received FDA approval and may appear on some formularies at a lower cost-sharing tier. Security Health Plan's formulary should be checked directly, as biosimilar placement varies by plan year. A 2023 analysis in the Journal of Managed Care & Specialty Pharmacy found that biosimilar availability reduced average plan costs for teriparatide by 15% to 25%, though patient savings depended heavily on formulary tier placement [12].

How to Submit a Prior Authorization Request

The prior authorization process involves the prescribing provider, not the patient directly. The provider's office submits a request to Security Health Plan's pharmacy benefit manager with supporting clinical documentation.

Required documents typically include the most recent DXA scan report with T-scores, the patient's FRAX score calculation, a list of prior osteoporosis medications with dates of use, documentation of bisphosphonate failure or contraindication, and relevant lab work including serum calcium, 25-hydroxyvitamin D, and renal function. Initial review takes 5 to 10 business days for standard requests. Urgent or expedited requests, appropriate when there is imminent fracture risk, receive a decision within 72 hours [13].

The provider should use ICD-10 code M80 (osteoporosis with pathological fracture) or M81 (osteoporosis without pathological fracture) along with the appropriate site-specific codes. Using the fracture code when applicable strengthens the case for medical necessity. The National Osteoporosis Foundation (now the Bone Health & Osteoporosis Foundation) recommends that providers include fracture risk assessment documentation with every prior authorization for anabolic bone agents [14].

If the initial submission lacks sufficient documentation, Security Health Plan may issue a "request for additional information" rather than a flat denial. Responding promptly to these requests (within 10 business days) prevents the need to restart the entire process.

What to Do If Coverage Is Denied

A denial is not the final answer. Security Health Plan members have the right to appeal coverage decisions through both internal and external review processes.

The first step is an internal appeal filed within 180 days of the denial notice. The appeal should include a letter from the prescribing physician explaining why Forteo is medically necessary for this specific patient. New clinical information not included in the original request strengthens the appeal. Peer-reviewed literature supporting teriparatide over bisphosphonates for the patient's specific fracture risk profile should be attached.

The American Association of Clinical Endocrinology (AACE) 2020 guidelines state that "anabolic therapy is recommended as initial treatment in patients at very high fracture risk, including those with recent fractures, fractures while on approved osteoporosis therapy, multiple fractures, fractures while on drugs causing skeletal harm, very low T-scores (below -3.0), high risk for falls, or very high FRAX probability" [15]. Including this guideline language in the appeal letter directly addresses common denial rationales.

If the internal appeal is denied, members can request an external review through the Wisconsin Office of the Commissioner of Insurance. An independent review organization (IRO) evaluates the case using board-certified specialists. External review decisions are binding on the health plan. Data from the Wisconsin OCI show that approximately 40% to 50% of external reviews for specialty medication denials are overturned in the patient's favor [16].

Forteo Coverage for Medicare Advantage Members

Security Health Plan offers Medicare Advantage plans (Security Health Plan Medicare) in select Wisconsin counties. Coverage for Forteo under these plans follows Medicare Part D pharmacy benefit rules rather than the commercial formulary.

Under Medicare Part D, Forteo is classified as a specialty tier medication. The standard Part D benefit structure in 2026 includes an annual out-of-pocket cap of $2,000, after which the member pays nothing for covered prescriptions [17]. This cap, introduced by the Inflation Reduction Act, significantly reduces the financial burden for Medicare beneficiaries using high-cost specialty medications like Forteo.

Prior authorization requirements still apply under the Medicare Advantage pharmacy benefit. The criteria are similar to commercial plans but must comply with CMS coverage determination guidelines. Medicare cannot impose step therapy that contradicts accepted clinical guidelines for patients with very high fracture risk. If a Medicare Advantage plan denies Forteo coverage, beneficiaries can file a Part D coverage determination request and, if needed, appeal to the Independent Review Entity (IRE) [18].

Comparing Forteo to Other Covered Osteoporosis Medications

Understanding where Forteo fits among covered alternatives helps patients and providers choose the right therapy and anticipate coverage decisions.

Oral bisphosphonates (alendronate, risedronate) sit on the lowest formulary tier, often Tier 1 or 2, with copays under $10 per month. These are the plan's preferred first-line agents. Zoledronic acid (Reclast), given as an annual IV infusion, is covered under the medical benefit rather than the pharmacy benefit and typically requires separate preauthorization. Denosumab (Prolia), a twice-yearly subcutaneous injection, occupies a specialty tier similar to Forteo and also requires prior authorization [19].

The ARCH trial (N=4,093) demonstrated that romosozumab (Evenity) followed by alendronate reduced vertebral fracture risk by 48% compared to alendronate alone over 24 months [20]. Romosozumab is another anabolic option but carries a cardiovascular warning and may face even stricter prior authorization criteria than Forteo under Security Health Plan.

The DATA-Switch trial showed that patients treated with teriparatide followed by denosumab gained more bone density at the spine and hip than those receiving either drug alone [21]. This sequential approach is now endorsed by multiple guidelines but requires separate prior authorizations for each medication phase.

Duration Limits and Renewal Considerations

Forteo carries an FDA black-box warning limiting its use to 24 months based on osteosarcoma findings in rat studies at high doses. Security Health Plan enforces this 24-month treatment duration cap.

The original safety concern arose from preclinical studies in Fischer 344 rats exposed to teriparatide at doses 3 to 58 times the human dose for nearly their entire lifespan. A 15-year post-marketing surveillance study published in the Journal of Bone and Mineral Research found no increased osteosarcoma risk in humans treated with teriparatide [22]. The FDA maintained the boxed warning despite these reassuring human data, and health plans continue to enforce the 24-month limit.

Prior authorization for Forteo is typically granted in 6-month or 12-month intervals, requiring renewal documentation. Each renewal submission should include updated clinical notes, any new fracture events, and confirmation that the cumulative treatment duration has not exceeded 24 months. Providers should plan the transition to an antiresorptive agent (denosumab or a bisphosphonate) before the Forteo course ends, as stopping anabolic therapy without follow-on antiresorptive treatment leads to rapid bone density loss within 12 months [23].

The Endocrine Society recommends that "an antiresorptive agent should be prescribed when the anabolic therapy course is completed to maintain the gains in bone density" [6]. Teriparatide 20 mcg daily for 24 months followed by denosumab 60 mg every 6 months produces sustained bone density gains at both the spine (+18.3%) and hip (+6.8%) over 4 years of combined sequential therapy [24].