CurrentAnthemPolicy N/A

Prior Authorization Form — FORTEO® (teriparatide) or TYMLOS™ (abaloparatide)

This document is a prior authorization (PA) form used by Anthem HealthKeepers Plus Medicaid for requesting coverage of FORTEO or TYMLOS; it defines prescriber submission requirements and clinical information needed to support PA decisions.

Policy Summary

PayerAnthem

PolicyPrior Authorization Form — FORTEO or TYMLOS

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete and sign the PA form with member demographics, prescriber NPI, drug details, diagnosis, prior bisphosphonate trials or contraindication, fracture risk data, DXA/T-scores, and prior parathyroid hormone analog use.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1form per member required

≥2bisphosphonate trials required (asks)

24 momax prior PTH analog therapy queried

18+age requirement queried

Coverage and Medical Necessity Criteria

Initial therapy/approval considerations

Form requests information that supports medical necessity; coverage would be considered when the following elements are provided and verifiable.

Baseline eligibility: Member is 18 or older AND has a confirmed diagnosis of osteoporosis

asks both items on form

Prior therapy requirement: Either therapeutic failure/inadequate response to at least two bisphosphonates OR inability/contraindication to receive bisphosphonates

form asks about ≥2 bisphosphonates and alternative justification if NO

High fracture risk or severe osteoporosis: One or more of: documented hip DXA or lumbar spine T-score ≤ -2.5; BMD -3 or worse; postmenopausal woman with non-traumatic fracture(s); postmenopausal woman with two or more specified clinical risk factors (family history, DXA T-score ≤ -2.5, >2 alcoholic drinks/day, chronic glucocorticoid use, prior fracture, rheumatoid arthritis, current smoker)

Policy Summary

PayerAnthem

PolicyPrior Authorization Form — FORTEO or TYMLOS

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Key Thresholds and Limits

inv-04: Maximum prior parathyroid hormone analog therapy — 24 months

Maximum cumulative duration24 months total maximum prior therapy with parathyroid hormone analogs

Documented on PA formForm asks: 'Member has not received therapy with parathyroid hormone analogs (e.g., Forteo) in excess of 24 months in total?'

Impact on approvalPrior exposure exceeding 24 months is queried as a limit to initial therapy/approval

inv-05: DXA T-score threshold for osteoporosis — -2.5 (or -3.0 for severe BMD question)

Primary DXA thresholdT-score ≤ -2.5 at hip (femoral neck or total hip) or lumbar spine defines osteoporosis

Severe BMD considerationBMD of -3.0 or worse is specifically queried on the form as severe osteoporosis

Use in risk groupingDXA thresholds are used to identify high fracture risk for anabolic therapy consideration

Definitions and Risk Indicators

inv-11: Prior parathyroid hormone analog exposure — whether member received therapy in excess of 24 months

PA form questionForm explicitly asks whether member has received parathyroid hormone analogs in excess of 24 months

Response optionsYes/No checkbox on PA form to indicate prior exposure >24 months

Verification requirementPrescriber signature attests information is accurate and verifiable by member records

inv-12: High fracture risk indicators — prior non-traumatic fractures, DXA BMD T-score ≤ -2.5, prolonged glucocorticoid use, etc.

Prior non‑traumatic fracture(s)History of non‑traumatic fracture(s) is listed as a high fracture risk indicator

DXA BMD T-scoreT-score ≤ -2.5 at hip or lumbar spine qualifies as high fracture risk

Severe low BMDBMD of -3.0 or worse is queried as severe osteoporosis

Prolonged glucocorticoid useGlucocorticoid use ≥6 months at 7.5 mg prednisolone equivalent is a risk factor

Other clinical risk factorsFamily history of fracture, rheumatoid arthritis, current smoking, and >2 alcoholic beverages/day are listed as risk factors

Provider Submission Requirements and Warnings

Prior Authorization

Prior Authorization Form Completion Required

A completed and signed prior authorization (PA) form is required for FORTEO/TYMLOS requests. The prescriber must complete and sign the form; by signing, the physician confirms the information is accurate and verifiable by member records. Fax the completed form to 844-512-7020. Incomplete or illegible information may delay the PA process; submission of documentation does not guarantee coverage.

Provider must complete all required sections of the PA form, including member demographics, prescriber information (including NPI), drug name/form, strength, dosing frequency, length of therapy, and quantity.
Provider must sign and date the PA form; unsigned forms will delay processing.
Fax completed form to 844-512-7020 or contact Anthem HealthKeepers Plus Provider Services at 800-901-0020 with questions.
Ensure all entries are legible and accurate; illegible or incorrect information may delay or prevent approval.

Step Therapy

Bisphosphonate Requirement and Documentation

The PA form specifically asks whether the member has had therapeutic failure or an inadequate response to at least two bisphosphonates, or whether the member is unable to receive or has a contraindication to bisphosphonates. Provide details where requested.

Answer the bisphosphonate question(s) on the form: indicate Yes/No for therapeutic failure/inadequate response to ≥2 bisphosphonates.
If the member has not failed two bisphosphonates, document the contraindication or inability to receive bisphosphonates and provide supporting details.
Include any supporting records (e.g., prior medication history, intolerance documentation) when submitting the PA form.

Documentation Required

PA Form Clinical Details Required

The PA form requires completion of diagnosis and medical information fields (age, confirmed osteoporosis diagnosis, fracture risk, DXA/BMD results, prior parathyroid hormone analog exposure, calcium/vitamin D supplementation plans, and other clinical risk factors). Ensure all relevant clinical fields are completed.

Complete all diagnosis and medical information checkboxes, including age, osteoporosis diagnosis, fracture risk, DXA/BMD T-scores, and history of non-traumatic fractures.
Document whether the member will receive calcium and vitamin D supplementation if dietary intake is inadequate.
Confirm duration of prior parathyroid hormone analog therapy (must not exceed 24 months total).

Denial Risk

Incomplete/Incorrect Form Warning

Incomplete, incorrect, or illegible PA forms may delay the authorization process. Submission of documentation does not guarantee coverage.

Illegible or missing prescriber signature, missing NPI, or incomplete drug/dosage information can delay processing.
Use one form per member and ensure all pages are completed where indicated ('Form continued on next page').

OpenPayer

Prior Authorization Form — FORTEO® (teriparatide) or TYMLOS™ (abaloparatide)

Coverage and Medical Necessity Criteria

Key Thresholds and Limits

Definitions and Risk Indicators

Provider Submission Requirements and Warnings

Clinical Background