teriparatide — Blue Cross Blue Shield of Illinois

Preferred products

• FORTEO generic equivalent
• Tymlos (abaloparatide)

Initial criteria

• The generic equivalent is not in the best interest of the patient based on medical necessity OR the patient has tried another prescription drug in the same pharmacologic class or mechanism as the generic equivalent and it was discontinued due to lack of efficacy or adverse event
• The patient will NOT use 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)
• The patient does NOT have any FDA labeled contraindications to the requested agent
• 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) total duration has exceeded 2 years and the patient is at high risk of fracture (e.g., T-score, FRAX score, or chronic glucocorticoid use ≥5 mg prednisone daily)
• For residents of Ohio with Fully Insured or HIM Shop (SG) plans: no FDA labeled contraindications AND (i) another FDA labeled indication OR (ii) another compendia-supported indication OR (iii) prescriber submitted two peer-reviewed journal articles supporting safe and effective use
• For teriparatide (non-preferred):
• 1. ONE of the following: (A) osteoporosis diagnosis meeting sex, age, and diagnostic confirmation requirements (fragility fracture, T-score ≤ -2.5, or FRAX higher risk thresholds) AND evidence of very high fracture risk OR (B) condition related to stage four advanced metastatic cancer with use supported by evidence and FDA approval OR (C) tried and had inadequate response/intolerance/contraindication to a bisphosphonate
• 2. ONE of the following step-therapy exceptions: patient has stage four metastatic cancer; OR requested agent is FORTEO generic equivalent; OR patient is currently stable on requested agent; OR tried and failed both preferred agents (FORTEO generic equivalent AND Tymlos (abaloparatide)); OR both preferred agents discontinued due to insufficient efficacy or adverse events; OR intolerance or contraindication to both preferred agents; OR both preferred agents expected ineffective or cause adherence barrier, comorbid condition worsening, or adverse reaction; OR both preferred agents not in best interest based on medical necessity; OR tried another drug from same class with inadequate response or adverse event
• For glucocorticoid-induced osteoporosis: patient on glucocorticoids ≥5 mg prednisone daily for at least 3 months AND age <40 years with prior fracture, or prednisone cumulative dose ≥5g/year, or ≥30 mg/day; OR age ≥40 years with prior osteoporotic fracture, T-score ≤ -2.5, FRAX ≥20% major or ≥3% hip, or glucocorticoid exposure meeting same thresholds

Approval duration

12 months (up to total of 2 years lifetime for all parathyroid hormone analogs; if exceeded 2 years and patient high risk of fracture, approve 1 year)