Forteo — CareFirst (Caremark)

Preferred products

• zoledronic acid (Reclast)
• denosumab (Prolia, Jubbonti, Ospomyv, Stoboclo)
• denosumab-bbdz (Jubbonti)
• abaloparatide (Tymlos)
• oral bisphosphonates

Initial criteria

• Postmenopausal Osteoporosis: Authorization of an initial total of 12 months may be granted when EITHER of the following is met: (1) member has a history of fragility fractures (e.g., low trauma fracture from force similar to a fall from standing position); OR (2) member has a pre-treatment T-score ≤ -2.5 OR osteopenia (T-score > -2.5 and < -1) with a high pre-treatment FRAX fracture probability AND ANY of the following: indicators of very high fracture risk (e.g., advanced age, frailty, glucocorticoid use, very low T-scores ≤ -3, or increased fall risk); failure or intolerance to previous injectable osteoporosis therapy (e.g., zoledronic acid [Reclast], denosumab product [Prolia, Jubbonti, Ospomyv, Stoboclo], denosumab-bbdz [Jubbonti], abaloparatide [Tymlos]); or an oral bisphosphonate trial of at least 1-year duration or clinical reason to avoid oral bisphosphonate.
• Primary or Hypogonadal Osteoporosis in Men: Authorization of an initial total of 12 months may be granted when EITHER of the following is met: (1) member has a history of an osteoporotic vertebral or hip fracture; OR (2) member meets BOTH: pre-treatment T-score ≤ -2.5 OR osteopenia (T-score > -2.5 and < -1) with high pre-treatment FRAX fracture probability AND has had an oral or injectable bisphosphonate trial of at least 1-year duration OR clinical reason to avoid bisphosphonate.
• Glucocorticoid-Induced Osteoporosis: Authorization of an initial total of 12 months may be granted when ALL of the following are met: (1) oral or injectable bisphosphonate trial ≥ 1-year duration OR clinical reason to avoid bisphosphonate; AND (2) member is currently receiving or will be initiating glucocorticoid therapy at equivalent prednisone dose ≥ 2.5 mg/day for ≥ 3 months; AND (3) ANY of: history of fragility fracture, pre-treatment T-score ≤ -2.5, or osteopenia (T-score > -2.5 and < -1) with high pre-treatment FRAX fracture probability.

Reauthorization criteria

• Authorization of 12 months may be granted for members currently receiving teriparatide who meet one of the following: (1) member has received less than 24 months of therapy and has not experienced clinically significant adverse events during therapy; OR (2) member has received 24 months or more and has experienced clinical benefit (improvement or stabilization in T-score since previous bone mass measurement) and has not experienced adverse effects.

Approval duration

12 months (initial and continuation), cumulative parathyroid hormone analog therapy not to exceed 24 months lifetime unless member remains at or returns to high fracture risk.