Teriparatide (Forteo®) Prior Authorization Criteria

Teriparatide (Forteo®) Authorization Request Form

Covered Uses

• Post menopausal women with diagnosis of osteoporosis confirmed by bone densitometry  (DXA) which evidence a T score equal or less than -2.5 (T-2.5 deviations of the mean peak bone mass in adults) at high risk for fracture, with any of the following:
  • History of osteoporotic fracture OR
  • Multiple risk factors for fracture OR
  • Failure to  previous osteoporosis therapy OR
  • Intolerance to previous osteoporotic therapy
• Men with primary or hypogonadal osteoporosis diagnosis confirmed by bone densitometry  (DXA) which evidence a T score equal or less than -2.5 (T-2.5 deviations of the mean peak bone mass in adults) at high risk for fracture, with any of the following:
  • History of osteoporotic fracture OR
  • Multiple risk factors for fracture OR
  • Failure to  previous osteoporosis therapy OR
  • Intolerance to previous osteoporotic therapy
• Men and women  with osteoporosis associated with sustained systemic glucocorticoid therapy (daily dose equivalent to 5mg or greater of prednisone) at high risk for fracture with any of the following:
  • History of osteoporotic fracture OR
  • Multiple risk factors for fracture OR
  • Failure to  previous osteoporosis therapy OR
  • Intolerance to previous osteoporotic therapy

Exclusion Criteria

None

Required Medical Information

• Document the T score
• Document previous fracture (if applicable)
• Document risk factors for osteoporosis
• Document previous osteoporosis therapy
• Document type of intolerance to previous osteoporosis therapy

Age Restrictions

None

Prescriber Restrictions

• Endocrinologist
• Rheumatologist

Coverage Duration

Every prescription is authorized for up to six (6) months depending on refills written in prescription up to two (2) years

Other Criteria

None