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

Preferred products

• FORTEO generic equivalent
• Tymlos (abaloparatide)

Initial criteria

• The patient will NOT be using 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. 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 of treatment with parathyroid hormone analog(s) for osteoporosis has exceeded 2 years in a lifetime AND the 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 with Fully Insured or HIM Shop (SG) plans: patient has no FDA labeled contraindications AND (has another FDA labeled or compendia-supported indication, or use supported by two peer-reviewed journal articles)
• For Teriparatide (non-preferred): ONE of the following: (A) Osteoporosis AND subcriteria: (1) patient is male age ≥50 years OR medically appropriate, or female postmenopausal or medically appropriate AND (2) diagnosis confirmed by fragility fracture of hip or spine OR T-score ≤ -2.5 OR T-score -1.0 to -2.5 with fragility fracture or FRAX 10-year major fracture risk ≥20% or hip fracture risk ≥3% AND (3) ONE of the following: patient at very high fracture risk defined by recent fracture (within 12 months), multiple fractures, fracture on therapy, fractures while on long-term glucocorticoids, T-score < -3.0, high fall risk, or high FRAX risk OR has tried and failed or is contraindicated/intolerant to bisphosphonate; OR (B) Glucocorticoid-induced osteoporosis AND ALL of the following: (1) currently taking glucocorticoids equivalent to ≥5 mg prednisone daily for ≥3 months AND (2) age <40 years with prior fracture or high glucocorticoid exposure (≥30 mg/day for ≥30 days or ≥5 g/year), OR age ≥40 years with prior osteoporotic fracture, T-score ≤ -2.5, FRAX 10-year major osteoporotic fracture ≥20% or hip fracture ≥3%, or high glucocorticoid exposure (≥30 mg/day >30 days or ≥5 g/year)
• Step therapy rule: patient must have tried, failed, or has contraindication/intolerance to BOTH preferred agents (FORTEO generic equivalent AND Tymlos (abaloparatide)) unless medically inappropriate or not in the patient’s best interest

Approval duration

12 months (up to 2 years lifetime total parathyroid hormone analog therapy); up to 1 year if already 2 years but at high risk of fracture