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Teriparatide — Blue Cross Blue Shield of Illinois

osteoporosis

Preferred products

  • FORTEO generic equivalent

Initial criteria

  • ONE of the following:
  • 1. ONE of the following: A. The prescriber has stated that the patient has been diagnosed with stage four advanced metastatic cancer and the requested agent is being used to treat the cancer OR B. The prescriber has submitted documentation that the patient has been diagnosed with stage four advanced metastatic cancer and the requested agent is being used to treat an associated condition related to stage four advanced metastatic cancer [chart notes required] AND
  • 2. The use of the requested agent is consistent with best practices for the treatment of stage four advanced metastatic cancer, or an associated condition; supported by peer-reviewed, evidence-based literature; and approved by the United States Food and Drug Administration OR
  • 3. The requested agent is FORTEO generic equivalent OR
  • 4. The patient is currently being treated with the requested agent and is currently stable on the requested agent [chart notes required] OR
  • 5. The patient has tried and had an inadequate response to FORTEO generic equivalent OR
  • 6. FORTEO generic equivalent was discontinued due to lack of efficacy, diminished effect, or an adverse event [chart notes required] OR
  • 7. The patient has intolerance or hypersensitivity to FORTEO generic equivalent that is not expected to occur with the requested agent OR
  • 8. The patient has an FDA labeled contraindication to FORTEO generic equivalent that is not expected to occur with the requested agent OR
  • 9. FORTEO generic equivalent is expected to be ineffective based on known clinical characteristics, cause a significant barrier to adherence, worsen a comorbid condition, decrease functional ability, or cause adverse reaction or harm [chart notes required] OR
  • 10. FORTEO generic equivalent is not in the best interest of the patient based on medical necessity [chart notes required] OR
  • 11. The patient has tried another prescription drug in the same pharmacologic class or mechanism of action as FORTEO generic equivalent and that drug was discontinued due to lack of efficacy, diminished effect, or an adverse event [chart notes required] AND
  • The patient will NOT be using the requested agent in combination with a bisphosphonate, denosumab (e.g., Prolia, Xgeva), romosozumab-aqqg, or another parathyroid hormone analog for osteoporosis (e.g., abaloparatide) AND
  • The patient does NOT have any FDA labeled contraindications to the requested agent AND
  • ONE of the following: A. Total duration of treatment with parathyroid hormone analog(s) for osteoporosis has NOT exceeded 2 years in a lifetime OR B. If total duration has exceeded 2 years, patient is at high risk of fracture (e.g., T-score, FRAX score, continued glucocorticoid use)

Approval duration

12 months (up to total 2 years lifetime)