FORTEO (teriparatide) — Blue Cross Blue Shield of Montana

Initial criteria

• 1. The prescriber has stated or submitted documentation that the patient has been diagnosed with stage four advanced metastatic cancer AND the requested agent is being used to treat the cancer OR an associated condition related to stage four advanced metastatic cancer AND the use of the requested agent is consistent with best practices, evidence-based literature, and FDA-approved use OR
• 2. The patient has tried and had an inadequate response to a bisphosphonate (medical records required) OR
• 3. The patient has an intolerance or hypersensitivity to a bisphosphonate (medical records required) OR
• 4. The patient has an FDA labeled contraindication to ALL bisphosphonates (medical records required) OR
• 5. The requested agent is FORTEO generic equivalent OR
• 6. The patient is currently being treated with the requested agent and is stable on therapy [chart notes required] OR
• 7. The patient has tried and had an inadequate response to FORTEO generic equivalent OR
• 8. FORTEO generic equivalent was discontinued due to lack of efficacy or adverse event [chart notes required] OR
• 9. The patient has intolerance, hypersensitivity, or labeled contraindication to FORTEO generic equivalent that is not expected with requested agent OR
• 10. FORTEO generic equivalent is expected to be ineffective, worsen comorbidities, or not be in the best interest of the patient [chart notes required] OR
• 11. The patient has tried another prescription drug in the same class or with the same mechanism as FORTEO generic equivalent and discontinued due to lack of efficacy or adverse event [chart notes required] AND
• 12. 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) AND
• 13. The patient does NOT have any FDA labeled contraindications to the requested agent AND
• 14. ONE of the following applies: (A) total duration of parathyroid hormone analog treatment for osteoporosis has NOT exceeded 2 years in a lifetime OR (B) treatment has exceeded 2 years but patient is at high fracture risk (e.g., T‑score, FRAX, glucocorticoid use ≥5 mg prednisone equivalent daily).

Reauthorization criteria

• Continuation may be approved if patient remains stable on therapy, continues to meet initial criteria including no contraindications, no concurrent therapy with bisphosphonate/denosumab/romosozumab/other PTH analog, and total treatment time remains within limits (≤2 years lifetime unless high fracture risk).

Approval duration

12 months (up to lifetime total 2 years; up to 1 year if high fracture risk and already ≥2 years)