Teriparatide (non-preferred) — Blue Cross Blue Shield of Montana

Preferred products

• FORTEO generic equivalent
• Tymlos (abaloparatide)

Initial criteria

• 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)
• Patient does NOT have any FDA labeled contraindications to the requested agent
• Total lifetime duration of treatment with parathyroid hormone analog(s) for osteoporosis has NOT exceeded 2 years OR has exceeded 2 years AND patient is at high risk of fracture (e.g., shown by T-score, FRAX score, continued use of glucocorticoids ≥ 5 mg prednisone daily)
• For Ohio members in Fully Insured or HIM Shop (SG) plans: Patient does NOT have contraindications AND has either an FDA-labeled indication, a compendia-supported indication, or prescriber-submitted evidence with two peer-reviewed articles supporting safe and effective use
• For osteoporosis indication: patient criteria include -
• • Male ≥ 50 years OR medically appropriate for age/sex OR Female postmenopausal OR medically appropriate for sex/menopause status
• • Diagnosis confirmed by: fragility fracture in hip or spine OR T-score ≤ -2.5 OR T-score between -1.0 and -2.5 with fragility fracture of proximal humerus, pelvis, or distal forearm OR FRAX 10-year probability ≥ 20% for major osteoporosis fracture or ≥ 3% for hip fracture
• • ONE of the following: (A) patient at very high fracture risk (recent fracture <12 months, fractures while on therapy or on skeletal-harming drugs, multiple fractures, T-score < -3.0, high fall risk, FRAX major ≥30% or hip ≥4.5%), OR (B) treated for stage IV metastatic cancer consistent with evidence-based, FDA-approved use, OR (C) inadequate response or intolerance/contraindication to a bisphosphonate
• Step therapy: requested agent approved if patient currently stable on it OR has tried and failed both preferred agents (FORTEO generic equivalent AND Tymlos (abaloparatide)) OR discontinued both for lack of efficacy or adverse event, OR has intolerance or contraindication to both preferreds OR both expected ineffective/inappropriate/not in best interest OR patient tried another drug in same class discontinued for lack of efficacy (chart notes required)
• For glucocorticoid-induced osteoporosis: Patient is initiating or currently taking glucocorticoids ≥5 mg/day prednisone equivalent for expected ≥3 months AND meets one of below age-based criteria:
• • Age <40 years AND (prior fracture OR glucocorticoid ≥30 mg/day OR cumulative dose ≥5 g/year)
• • Age ≥40 years AND (prior osteoporotic fracture OR T-score ≤ -2.5 OR FRAX major ≥20% OR hip ≥3% OR glucocorticoid ≥30 mg/day >30 days OR ≥5 g/year cumulative dose)

Approval duration

12 months (up to total 2 years lifetime, or 1 year if already completed 2 years and high risk)