FORTEO — Blue Cross Blue Shield of Oklahoma

osteoporosis

Preferred products

1. The patient has been diagnosed with osteoporosis OR has stage four advanced metastatic cancer or associated condition AND supporting chart notes are submitted.
2. The use of the requested agent is consistent with best practices and FDA approved use for the condition.
3. The patient has tried and had an inadequate response to a bisphosphonate OR has intolerance or hypersensitivity to a bisphosphonate OR has an FDA labeled contraindication to ALL bisphosphonates.
4. The patient will NOT be using the requested agent in combination with a bisphosphonate, denosumab (Prolia, Xgeva), romosozumab-aqqg, or another parathyroid hormone analog for osteoporosis (e.g., abaloparatide).
5. The patient does NOT have any FDA labeled contraindications to the requested agent.
6. ONE of the following applies: A. The total duration of treatment with parathyroid hormone analog(s) for osteoporosis has NOT exceeded 2 years in a lifetime OR B. The total duration has exceeded 2 years AND the patient is at high risk of fracture (evidenced by T-score, FRAX, or glucocorticoid use ≥5 mg prednisone daily).
7. FOR Ohio members with Fully Insured or HIM Shop plans: No FDA labeled contraindications AND EITHER: another FDA labeled indication for the agent and route, or compendia-supported indication, or two peer-reviewed journal articles supporting the use.

1. The patient continues to meet the initial criteria including diagnosis and contraindication considerations.
2. The total cumulative duration of therapy with parathyroid hormone analog(s) does not exceed 2 years, unless the patient remains at high fracture risk.

12 months (up to total of 2 years lifetime; up to 1 year if exceeded 2 years and at high fracture risk)