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FORTEO (teriparatide) — Blue Cross Blue Shield of New Mexico

osteoporosis

Preferred products

  • FORTEO generic equivalent

Initial criteria

  • Agent is being used to treat an associated condition related to stage four advanced metastatic cancer AND use is consistent with best practices for treatment of stage four metastatic cancer, supported by peer-reviewed, evidence-based literature, and FDA approved OR
  • Patient has tried and had an inadequate response to a bisphosphonate OR
  • Patient has an intolerance or hypersensitivity to a bisphosphonate OR
  • Patient has an FDA labeled contraindication to ALL bisphosphonates AND
  • ONE of the following:
  • Prescriber has documented diagnosis of stage four advanced metastatic cancer and requested agent is used to treat cancer or related condition AND use is consistent with best practices and FDA approved OR
  • Requested agent is FORTEO generic equivalent OR
  • Patient is currently treated and stable on the requested agent [chart notes required] OR
  • Patient has tried and had inadequate response to FORTEO generic equivalent OR
  • FORTEO generic equivalent discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
  • Patient has intolerance or hypersensitivity to FORTEO generic equivalent not expected with requested agent OR
  • Patient has an FDA labeled contraindication to FORTEO generic equivalent not expected with requested agent OR
  • FORTEO generic equivalent expected to be ineffective, cause adherence issues, worsen comorbidity, reduce function, or cause adverse reaction [chart notes required] OR
  • FORTEO generic equivalent not in best interest based on medical necessity [chart notes required] OR
  • Patient tried another prescription drug in the same class or mechanism as FORTEO generic equivalent discontinued for lack of efficacy or adverse event [chart notes required] AND
  • Patient will NOT be using the requested agent with bisphosphonate, denosumab (Prolia, Xgeva), romosozumab-aqqg, or another parathyroid hormone analog for osteoporosis (e.g., abaloparatide) AND
  • Patient does NOT have any FDA labeled contraindications to requested agent AND
  • ONE of the following:
  • Total duration of parathyroid hormone analog therapy has NOT exceeded 2 years lifetime OR
  • Total duration exceeded 2 years lifetime AND patient is at high risk of fracture (e.g., T-score, FRAX, glucocorticoids ≥5 mg prednisone daily)
  • Additional approval for members residing in Ohio with Fully Insured or HIM Shop (SG) plans when NO FDA labeled contraindications AND either an FDA labeled indication, compendia-supported indication, or two peer-reviewed journal articles support use

Approval duration

12 months; total up to 2 years lifetime or 1 year if >2 years and high risk fracture