Teriparatide (branded generic) — CareFirst (Caremark)

Preferred products

• zoledronic acid [Reclast]
• denosumab products [Prolia, Jubbonti, Ospomyv, Stoboclo]
• abaloparatide [Tymlos]
• oral bisphosphonates

Initial criteria

• For postmenopausal osteoporosis: Authorization of 12 months may be granted when EITHER of the following criteria 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 (pre-treatment T-score > -2.5 and < -1) with high pre-treatment FRAX fracture probability AND meets ANY of the following: indicators of very high fracture risk (e.g., advanced age, frailty, glucocorticoid use, T-score ≤ -3, increased fall risk); failed or intolerant to prior injectable osteoporosis therapy (e.g., zoledronic acid [Reclast], a denosumab product [Prolia, Jubbonti, Ospomyv, Stoboclo], denosumab-bbdz [Jubbonti], abaloparatide [Tymlos]); had an oral bisphosphonate trial of ≥ 1 year or clinical reason to avoid oral bisphosphonate (Appendix A).
• For primary or hypogonadal osteoporosis in men: Authorization of 12 months may be granted when EITHER of the following is met: (1) Member has a history of 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 had oral or injectable bisphosphonate trial of ≥ 1 year OR clinical reason to avoid bisphosphonate (Appendix A).
• For glucocorticoid-induced osteoporosis: Authorization of 12 months may be granted when ALL of the following are met: (1) Member had oral or injectable bisphosphonate trial of ≥ 1 year OR clinical reason to avoid bisphosphonate; (2) Member is currently receiving or will initiate glucocorticoid therapy at prednisone equivalent dose ≥ 2.5 mg/day for ≥ 3 months; (3) Member meets 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 when the member is currently receiving the medication through a previously authorized benefit AND either 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) and has not experienced adverse effects.

Approval duration

12 months (initial and continuation), total cumulative teriparatide/abaloparatide therapy ≤ 24 months lifetime unless member remains or returns to high fracture risk