CurrentHawaii Medical Service Association (HMSA)Policy N/A

Prior authorization criteria for parathyroid hormone analog therapy (Forteo) for osteoporosis

A prior authorization request form administered by CVS Caremark for HMSA members requesting coverage of parathyroid hormone analogs (e.g., Forteo) for osteoporosis including primary/postmenopausal, male osteoporosis, and glucocorticoid-induced osteoporosis. It governs clinician submission requirements for coverage decisions.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyPrior authorization criteria for parathyroid hormone analog therapy (Forteo) for osteoporosis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFax prior authorization request with required clinical documentation to CVS Caremark Specialty Programs at 1-866-237-5512.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3primary indication branches (initial therapy + 2 indication pathways)

≥24 monthslifetime treatment duration threshold

Many criteriadocumentation required

Faxsubmission route

Coverage Criteria for Parathyroid Hormone Analogs

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Initial and indication-specific coverage criteria

Coverage is considered when the specific indication pathway criteria are met as follows.

Initial request and indication selection: If this is an initial therapy request, prescriber must select the indication: treatment of osteoporosis in men or postmenopausal women OR treatment of glucocorticoid-induced osteoporosis. 'Other' leads to No Further Questions.

See indication-specific branches below

Osteoporosis in men or postmenopausal women — qualifying findings (any one): Coverage criteria met if ANY of the following are present: DEXA T-score ≤ -3.0; >2 vertebral fragility fractures; two moderate vertebral fragility fractures or reduction in vertebral body height 26-40%; one severe vertebral fragility fracture or reduction in vertebral body height >40%; pre-treatment T-score ≤ -2.5; history of vertebral or radial fracture.DEXA T-score thresholds and vertebral height reductions as specified

For each positive item, submit required DEXA or imaging as indicated on the form

Osteoporosis in men or postmenopausal women — alternative prior therapy pathway: If the member does not meet the numeric T-score or specified fracture criteria above, coverage may be considered when there is documentation of: an inadequate response or intolerable adverse event to at least a 1-year trial of an oral or injectable bisphosphonate; OR a clinical reason to avoid oral or injectable bisphosphonate; OR failure of or inability to tolerate ALL previous injectable osteoporosis therapies for which the member was eligible.≥1 year bisphosphonate trial

Supporting documentation must be submitted per the form

Glucocorticoid-induced osteoporosis — exposure and risk criteria: Member must have current or planned glucocorticoid therapy at a dose ≥ 2.5 mg/day prednisone equivalent for at least 3 months OR other risk features. Additionally, one of the following must be present: pre-treatment DEXA T-score ≤ -2.5; history of fragility fracture; T-score between -1.0 and -2.5 with high pre-treatment FRAX fracture probability; OR inadequate response/intolerance/clinical reason to avoid a ≥1-year trial of oral or injectable bisphosphonate.Glucocorticoid exposure: ≥ 2.5 mg/day for ≥ 3 months; DEXA thresholds as specified

Documentation of glucocorticoid dose/duration, DEXA results, FRAX, or imaging confirming fracture must be submitted

Continuation (lifetime cumulative duration): For continuation requests, provider must report cumulative lifetime months of prior parathyroid hormone analog therapy. A lifetime duration threshold of 24 months is captured on the form and affects continuation eligibility.24 months lifetime

Provider must attest to prior months and have documentation available for review

For the glucocorticoid-induced osteoporosis pathway, the form directs that if the member's pre‑treatment DEXA T‑score is greater than or equal to -1.0 at the femoral neck, total hip, or lumbar spine, the flow ends with No Further Questions. In other words, a T‑score ≥ -1.0 does not meet the numeric entry thresholds for this indication and no additional criteria will be requested on the form.

If the member does not meet any of the listed numeric DEXA T‑score thresholds, documented fragility‑fracture findings, or the required prior‑therapy failure/intolerance or clinical avoidance criteria, the form logic routes to a flow fallback of No Further Questions and the request will not meet the stated covered criteria. Providers should therefore ensure submission of supporting DEXA results, imaging confirming fractures, or documentation of an inadequate response/intolerance to at least a 1‑year trial of an oral or injectable bisphosphonate (or other documented clinical reason to avoid bisphosphonates) as applicable to avoid denial.

Diagnosis, Duration, and Assessment Codes / Values

Diagnosis code (provider-entered)ICD-10

ICD-10

ICD-10 diagnosis code to be provided by prescriber (blank on form)

Lifetime parathyroid hormone analog therapy duration — thresholds

Lifetime therapy durationLess than 24 months vs 24 months or greater (24-month threshold used to determine continuation eligibility)

Form questionAsks for cumulative months of parathyroid hormone analog therapy received in the member's lifetime

Routing logicIf <24 months, flow proceeds to initial therapy pathway; if ≥24 months, flow proceeds to continuation assessment of ongoing high fracture risk

DEXA T-score options and site specification

DEXA T-score categoriesT-score ≤ -3.0; T-score ≤ -2.5; T-score between -1.0 and -2.5; T-score ≥ -1.0

Anatomic sites acceptedFemoral neck, total hip, or lumbar spine (DEXA measurements at any of these sites as requested on form)

Action requiredCopy of DEXA scan results must be submitted when a qualifying T-score is indicated on the form

Vertebral body height reduction severity thresholds

Moderate vertebral height reduction26–40% reduction in vertebral body height

Severe vertebral height reductionGreater than 40% reduction in vertebral body height

DocumentationImaging studies supporting fracture or reduction in vertebral body height must be submitted when indicated

Clinically significant glucocorticoid exposure — dose/duration definition

Dose thresholdGreater than or equal to 2.5 mg per day of prednisone or equivalent

Duration thresholdFor at least 3 months

DocumentationDocumentation supporting the glucocorticoid dose and duration must be submitted when this criterion is selected

Submission Requirements, Prior Therapy, and Denial Triggers

Prior Authorization

Submission & approval note

Prior authorization requests must be submitted to CVS Caremark Specialty Programs. Fax the completed prior authorization form and all clinical documentation to 1-866-237-5512. For questions about the prior authorization decision, contact CVS Caremark at 1-808-254-4414. For inquiries about eligibility, copay, or medication delivery, contact CaremarkConnect® Specialty Customer Care at 1-800-237-2767. Approvals may be subject to dosing limits in accordance with FDA labeling, compendia, and evidence-based guidelines.

Send completed form and supporting documentation (DEXA, imaging, prior therapy records) to CVS Caremark Specialty Programs — Fax: 1-866-237-5512
Prior authorization questions: 1-808-254-4414
Specialty Customer Care (CaremarkConnect®): 1-800-237-2767

Documentation Required

Required supporting documentation

Providers must submit required supporting clinical documentation with the prior authorization request. Lack of required documentation may result in denial or delay of the request.

DEXA scan results — required when DEXA/T-score criteria are referenced (e.g., T-score ≤ -2.5 or ≤ -3.0).
Imaging studies supporting vertebral, radial, or other fragility fractures or documentation of vertebral body height reduction.
Documentation of glucocorticoid dose and duration when claiming glucocorticoid-induced osteoporosis (≥ 2.5 mg prednisone equivalent/day for ≥ 3 months).

Step Therapy

Prior therapy requirements

Prior therapy requirements must be documented when applicable. Failure to show required prior therapy or clinical rationale may lead to non-approval.

Documentation of an inadequate response or intolerable adverse event to at least a 1-year trial of an oral or injectable bisphosphonate, or a clinical reason to avoid bisphosphonates, when required.
When applicable, documentation that the member has failed or cannot tolerate ALL previous injectable osteoporosis therapies for which they are eligible (examples: Prolia, Tymlos, Evenity).
For glucocorticoid-induced osteoporosis, documentation of inadequate response/intolerance to or clinical reason to avoid at least a 1-year trial of an oral or injectable bisphosphonate.

Denial Risk

Denial triggers

Applications may be denied if required clinical criteria or documentation are missing or if numeric thresholds are not met.

Denial triggers include: absence of DEXA scan results when a T-score threshold is asserted, lack of imaging to support reported fractures, or missing documentation of prior therapy trials or reasons to avoid such therapies.
Numeric criteria not met (e.g., DEXA T-score thresholds, number/severity of vertebral fragility fractures) may result in denial.
Failure to document glucocorticoid dose/duration when claimed for glucocorticoid-induced osteoporosis can result in denial.

Key Definitions Used in Criteria

Definition of 'high risk for fracture'

High-risk attributesAny of: DEXA T-score ≤ -3.0; pre-treatment T-score ≤ -2.5; history of fragility fracture (vertebral or radial); multiple or moderate/severe vertebral fractures or significant vertebral height reduction; high pre-treatment FRAX probability

Glucocorticoid-related riskCurrent or planned glucocorticoid therapy ≥2.5 mg/day prednisone equivalent for ≥3 months counts toward high-risk considerations

Prior therapy failureInadequate response or intolerance to a ≥1‑year trial of an oral or injectable bisphosphonate (or clinical reason to avoid) supports high-risk designation when numeric criteria are not met

Required evidenceSupporting documentation such as DEXA results, imaging for fractures or vertebral height reduction, or FRAX calculation must be submitted to substantiate high-risk status

Clinically significant glucocorticoid exposure — definition

Glucocorticoid doseGreater than or equal to 2.5 mg per day prednisone equivalent

Glucocorticoid durationFor at least 3 months

Form requirementWhen selected, documentation supporting the glucocorticoid dose and duration must be submitted

Background

Parathyroid hormone analogs such as teriparatide (Forteo) are indicated in the form for patients at high risk for fracture, including men and postmenopausal women with severe osteoporosis or qualifying fracture histories, and for patients with glucocorticoid‑induced osteoporosis who meet the glucocorticoid exposure and risk/treatment‑failure criteria. The clinical rationale captured by the form is to reserve these anabolic agents for patients with markedly low bone density (e.g., DEXA T‑scores ≤ -3.0 or ≤ -2.5 depending on the branch), multiple or severe vertebral fragility fractures (including specified vertebral height reductions), or those who have failed or cannot tolerate first‑line antiresorptive therapy. For glucocorticoid‑treated patients the form requires documentation of glucocorticoid dose and duration (≥ 2.5 mg/day prednisone equivalent for at least 3 months) plus the same DEXA, fracture, or prior‑therapy evidence to support medical necessity.