Teriparatide — Blue Cross Blue Shield of Texas

Preferred products

• FORTEO generic equivalent
• Bonsity
• Teriparatide

Initial criteria

• Prescriber has stated or documented stage four advanced, metastatic cancer and requested agent is used to treat the cancer OR an associated condition related to stage four advanced metastatic cancer [chart notes required] AND use is consistent with best practices supported by evidence-based literature and FDA approval OR patient has tried and had an inadequate response to a bisphosphonate OR has an intolerance or hypersensitivity to bisphosphonate OR has an FDA labeled contraindication to ALL bisphosphonates [medical records required]
• Patient will NOT be using requested agent in combination with a bisphosphonate, denosumab (e.g., Prolia, Xgeva), romosozumab-aqqg, or another parathyroid hormone analog for osteoporosis (e.g., abaloparatide or teriparatide)
• Patient does NOT have any FDA labeled contraindications to the requested agent
• Total duration of treatment with parathyroid hormone analog(s) for osteoporosis has NOT exceeded 2 years in a lifetime OR if exceeded, patient is at high risk of fracture (e.g., T-score, FRAX score, continued glucocorticoid use at ≥5 mg prednisone daily)
• FORTEO generic equivalent specific step: requested agent is FORTEO generic equivalent OR patient is stable on requested agent OR inadequate response, intolerance, contraindication, or not in best interest to use FORTEO generic equivalent OR FORTEO generic expected to be ineffective or cause adverse outcome [chart notes required]
• Member resides in Ohio AND plan is Fully Insured or HIM Shop (SG) AND patient has no contraindications AND has FDA labeled or compendia supported indication OR prescriber has submitted 2 peer-reviewed journal articles supporting use

Approval duration

12 months (up to total 2 years lifetime)