Does SelectHealth Cover Forteo (Teriparatide)?

What Is Forteo and Why Is It Prescribed?

Forteo is a brand-name anabolic agent for osteoporosis, not merely a drug that slows bone loss. It is a recombinant fragment of human parathyroid hormone (PTH 1-34) that stimulates osteoblast activity, actively building new bone matrix rather than simply preventing resorption. The FDA approved teriparatide in November 2002 for postmenopausal women and men with osteoporosis at high fracture risk, and later for glucocorticoid-induced osteoporosis in both sexes [1].

The key Fracture Prevention Trial (commonly called the FRACTURE trial, N=1,637 postmenopausal women) showed that teriparatide 20 mcg/day reduced new vertebral fractures by 65% compared with placebo over a median 18 to 21 months of treatment (relative risk 0.35 to 95% CI 0.22-0.55, P<0.001) [2]. Non-vertebral fragility fractures fell by 53% in the same population. Those numbers explain why prescribers reach for Forteo when antiresorptives have failed or when bone density losses are severe.

The FDA label restricts total lifetime use to 24 cumulative months because early rat studies at supraphyprophysiologic doses raised osteosarcoma concerns [1]. No human case of osteosarcoma causally attributed to teriparatide has been confirmed in post-marketing surveillance spanning more than two decades, but the cap remains in place. SelectHealth PA approvals uniformly reflect this 24-month ceiling.

Teriparatide is also studied in atypical femur fracture healing and stress fractures, though those uses remain off-label. The American Association of Clinical Endocrinology (AACE) 2020 Clinical Practice Guidelines list teriparatide as a preferred anabolic agent for patients with very high fracture risk, defined as a T-score below -3.0 or a prior vertebral or hip fracture [3].

How SelectHealth Formularies Work for Specialty Drugs

SelectHealth, a not-for-profit health plan based in Utah and affiliated with Intermountain Health, structures its formulary in tiers. Generic drugs occupy Tiers 1 and 2. Preferred brand drugs sit at Tier 3. Non-preferred brands and most specialty injectables land on Tier 4 or a dedicated Specialty Tier 5 [4]. Forteo is a Tier 4 or 5 drug on SelectHealth commercial plans, which means the plan shares cost with the member only after prior authorization is approved and, on some plans, after a separate specialty deductible is met.

Medicare Part D plans administered by SelectHealth (through SelectHealth Medicare Advantage) use a parallel structure. CMS requires Part D plans to place most specialty drugs on the highest cost-sharing tier, typically Tier 5, with coinsurance ranging from 25% to 33% of the negotiated drug cost rather than a flat copay [5]. For a drug with an average wholesale price near $3,400 per 28-day pen, 25% coinsurance equals roughly $850 per month before any low-income subsidy or manufacturer assistance.

Formulary placement can shift each January when SelectHealth publishes its annual formulary update. The correct move before prescribing is to run a real-time eligibility check through SelectHealth's provider portal or call the pharmacy benefits number on the member's ID card. A formulary that covered Forteo at Tier 4 in 2024 may have added a step-therapy requirement or moved it to Tier 5 in 2025.

The National Council for Prescription Drug Programs (NCPDP) standard that governs electronic prior authorization (ePA) transactions means that most EHR systems can submit SelectHealth PA requests electronically, cutting average processing time from the historical five to seven business days to as few as 24 to 72 hours for routine submissions [6].

SelectHealth Prior Authorization Criteria for Forteo

Prior authorization for Forteo on SelectHealth plans typically requires the prescriber to document four categories of clinical information. First, a confirmed diagnosis of osteoporosis based on DXA T-score at or below -2.5 at the lumbar spine, total hip, or femoral neck, or a documented low-trauma (fragility) fracture of the spine, hip, wrist, or proximal humerus [7]. Second, evidence of high or very high fracture risk, often quantified with a FRAX 10-year probability score exceeding 20% for major osteoporotic fracture or 3% for hip fracture, per the National Osteoporosis Foundation thresholds [8].

Third, documentation that the patient has tried and failed at least one oral bisphosphonate (alendronate or risedronate) for a minimum of 6 to 12 months, or that a contraindication or intolerance to bisphosphonates exists. Common contraindications SelectHealth accepts include severe renal impairment (eGFR <35 mL/min/1.73 m²), esophageal motility disorders, and documented upper GI intolerance confirmed by prescriber notes rather than patient report alone [9]. Fourth, the prescriber must confirm the patient has no prior history of osteosarcoma, Paget disease of bone, unexplained alkaline phosphatase elevation, or prior skeletal radiation [1].

The HealthRX clinical team has synthesized these criteria into a four-point PA readiness checklist that mirrors what SelectHealth reviewers actually look for:

1. DXA report with T-score numerical value (not just "osteoporosis") dated within 24 months.
2. FRAX score printout or in-note calculation with country-specific values for the US population.
3. Pharmacy or prescription history confirming bisphosphonate dispensing dates and either a refill gap suggesting intolerance or a documented adverse event note.
4. Attestation that the 24-month lifetime cap has not been reached (relevant for patients restarting after a prior Forteo course).

Submitting all four items with the initial PA request reduces the likelihood of a pend or denial requesting additional information, which is the single most common reason SelectHealth specialty PA decisions are delayed past the standard 72-hour window.

What Happens If SelectHealth Denies the Forteo PA?

Denials are not final. SelectHealth must follow Utah state insurance code and federal CMS regulations for Medicare Advantage, both of which require a written denial with a specific clinical rationale and instructions for appeal [10]. Commercial plan members have the right to an internal appeal within 30 days of the denial date. Medicare Advantage members have rights to both an internal organization determination appeal and an expedited appeal within 72 hours if the prescriber attests that standard timeframes would seriously jeopardize health [5].

The most effective appeals include a signed letter of medical necessity from the treating physician, the complete DXA report, the FRAX calculation, and any peer-reviewed literature supporting Forteo as the appropriate agent. The AACE 2020 guidelines are particularly useful here because they explicitly state that anabolic therapy should be considered "first-line for patients at very high risk of fracture" [3]. Citing a named guideline carries more weight with SelectHealth's pharmacy and therapeutics reviewers than a general statement about clinical judgment.

External independent review is available if the internal appeal fails. In Utah, the Insurance Department oversees external review for commercial plans. For Medicare Advantage, CMS contracts with a Qualified Independent Contractor (QIC) to handle second-level appeals. Nationally, published data suggest specialty-drug appeals succeed roughly 40 to 60% of the time when the clinical record is complete and the prescriber participates in peer-to-peer review [11].

Peer-to-peer review, a direct conversation between the treating physician and a SelectHealth medical director, resolves a meaningful share of denials without formal appeal. Most SelectHealth PA denial letters include a phone number and a 72-hour window for requesting a peer-to-peer call. Endocrinologists and rheumatologists with documented subspecialty expertise in metabolic bone disease tend to be more persuasive in these calls than general practitioners, simply because the conversation can go deeper into fracture risk modeling and anabolic mechanism.

Cost Assistance Options While Awaiting or After Coverage Decisions

Eli Lilly operates the Lilly Cares Foundation patient assistance program, which can provide Forteo at no cost to commercially insured patients whose household income falls below 400% of the federal poverty level and who have exhausted insurance options [12]. The Lilly Insulin Value Program does not cover Forteo, so patients must apply specifically through the Lilly Cares channel.

For commercially insured patients who do have SelectHealth approval, Lilly's Forteo savings card historically reduced out-of-pocket costs to as low as $5 per month for eligible patients, though savings card availability and maximum benefit amounts change annually and are not available for Medicare or Medicaid enrollees [12]. The 340B Drug Pricing Program, available at qualifying health centers, can reduce acquisition cost by 20 to 50% for patients treated at federally qualified health centers that participate in the program, though those savings accrue to the facility rather than directly to the patient at point of sale [13].

GoodRx and similar discount programs do not typically produce meaningful savings on Forteo compared with the Lilly Cares program, because the drug's price is so high that percentage-based discounts still leave a large absolute cost. The most cost-effective path for patients who cannot get SelectHealth to cover Forteo is: (1) confirm denial in writing, (2) apply to Lilly Cares simultaneously with filing the internal appeal, and (3) ask the prescriber about Tymlos (abaloparatide), which has a comparable mechanism and may occupy a preferred specialty tier on the current SelectHealth formulary.

Tymlos and Romosozumab as Covered Alternatives

SelectHealth formularies sometimes list Tymlos (abaloparatide, Radius Health) at a lower specialty cost-share than Forteo, particularly when Forteo is non-preferred and abaloparatide holds a preferred specialty slot. Abaloparatide 80 mcg/day subcutaneous injection received FDA approval in April 2017 [14]. The ACTIVE trial (N=2,463) showed abaloparatide reduced new vertebral fractures by 86% vs. placebo (relative risk 0.14, P<0.001) and reduced non-vertebral fractures by 43% over 18 months [15]. Abaloparatide also carries a 24-month lifetime cap and similar PA criteria.

Romosozumab (Evenity, UCB/Amgen), a sclerostin inhibitor with both anabolic and antiresorptive properties, received FDA approval in April 2019 for postmenopausal women with osteoporosis at high fracture risk [16]. The FRAME trial (N=7,180) showed romosozumab 210 mg monthly subcutaneous injection reduced vertebral fractures by 73% vs. placebo at 12 months [17]. SelectHealth covers romosozumab under separate PA criteria that add a cardiovascular risk evaluation because the ARCH trial identified a numerical imbalance in serious cardiovascular events with romosozumab vs. alendronate [18]. Patients with prior myocardial infarction or stroke within 12 months should not use romosozumab per the FDA label [16].

If the SelectHealth formulary currently lists Evenity at a preferred specialty tier and Forteo at a non-preferred tier, switching to romosozumab may produce lower out-of-pocket cost with equivalent or greater fracture risk reduction over the 12-month treatment course. A prescriber with access to the current SelectHealth formulary document can make this comparison in under five minutes using the plan's online drug-cost lookup tool.

The Evidence Base Supporting Teriparatide in Specific Populations

Postmenopausal women represent the best-studied group, but teriparatide's approval extends to men and to both sexes with glucocorticoid-induced osteoporosis. In men with primary or hypogonadal osteoporosis, a randomized controlled trial (N=437) found teriparatide 20 mcg/day increased lumbar spine BMD by 5.9% vs. 0.5% with placebo at 11 months (P<0.001) [19]. That study informed the FDA label expansion to men.

Glucocorticoid-induced osteoporosis (GIOP) represents a population where anabolic therapy has particular appeal because glucocorticoids suppress osteoblast function directly. A randomized trial comparing teriparatide with risedronate in GIOP patients (N=428, mean daily prednisone equivalent 7.5 mg for at least 3 months) found teriparatide produced a statistically significant lower incidence of new vertebral fractures at 18 to 36 months (0.6% vs. 6.1%, relative risk 0.10, P=0.004) [20]. SelectHealth's PA criteria for GIOP may differ slightly from primary osteoporosis criteria. In particular, some versions of the SelectHealth GIOP criteria waive the bisphosphonate step-therapy requirement if the treating physician documents that glucocorticoid exposure is expected to continue for 3 or more months and the T-score is below -1.5 at any site.

Patients with chronic kidney disease present a special consideration. The FDA label notes that teriparatide has not been studied in patients with creatinine clearance below 30 mL/min [1]. SelectHealth PA reviewers may request a documented eGFR result as part of the submission for any patient with a history of renal disease, even if the eGFR is above 30. Including a recent basic metabolic panel with the PA submission pre-empts this request.

Practical Steps for Prescribers and Patients at SelectHealth

The prescriber's office handles the PA submission in most cases, but patients who understand the process get faster results. The sequence that works best in clinical practice runs as follows.

Step one: confirm the patient's current SelectHealth plan type (commercial HMO, commercial PPO, Medicare Advantage, or Medicaid) because formulary tier and PA requirements differ by product. Step two: pull the current formulary document from SelectHealth's website and verify Forteo's tier and any step-therapy requirement as of the current plan year. Step three: order or retrieve a DXA scan report dated within 24 months and calculate FRAX using the WHO Fracture Risk Assessment Tool [8]. Step four: document the bisphosphonate trial or contraindication in the medical record with specific dates and either a dispensing record or a described adverse event. Step five: submit the PA electronically through the EHR with all four documentation elements attached.

The Endocrine Society's 2019 clinical practice guideline on osteoporosis in postmenopausal women states that anabolic agents are appropriate as initial therapy for patients with very high fracture risk and should be followed by antiresorptive therapy to preserve BMD gains [21]. That sequential therapy principle matters for SelectHealth coverage planning: after 24 months of Forteo, a separate PA for a bisphosphonate or denosumab (Prolia) is typically needed, and the clinical record should already document the transition plan to avoid a coverage gap.

SelectHealth processes standard PA decisions within 3 business days for non-urgent requests and within 24 hours for urgent requests when the prescriber documents clinical urgency. Expedited requests require the prescriber to attest in writing that waiting the standard timeframe would place the patient at risk of serious health harm [10]. A patient who has already sustained an acute vertebral fracture and is at imminent risk of a second fracture qualifies for expedited review under that standard.

The American College of Rheumatology and the AACE both publish osteoporosis management guidelines that SelectHealth's pharmacy and therapeutics committee uses when setting PA criteria [3, 22]. Citing both guidelines in a letter of medical necessity, with specific page or section references rather than general mentions, strengthens the appeal record.

Monitoring Requirements During Teriparatide Treatment

SelectHealth does not typically require documented monitoring labs as a condition of continued PA approval, but the FDA label and AACE guidelines recommend periodic calcium and serum creatinine measurement because teriparatide transiently elevates serum calcium in roughly 11% of patients [1, 3]. Symptomatic hypercalcemia is uncommon but requires dose modification or discontinuation.

DXA monitoring at 12 months into a 24-month course documents anabolic response and provides evidence for continued PA renewal if SelectHealth requires an annual reauthorization, which some plan versions do. A lumbar spine BMD increase of 5% or more at 12 months is consistent with response in clinical trials [2] and can be cited in the renewal PA as objective evidence of therapeutic benefit.

The FDA mandates a Risk Evaluation and Mitigation Strategy (REMS) program for teriparatide, known as the Forteo REMS, requiring patient enrollment and a medication guide at dispensing [1]. Specialty pharmacies contracted with SelectHealth handle REMS enrollment automatically, but the prescribing physician's office should confirm enrollment is complete before the first pen is dispensed to avoid a dispensing delay.