Forteo policy criteria

[sdpharmd]

What criteria are used for Forteo policies? How do plans define prior treatment failure?

[diana.papshev]

Since many plans publish coverage criteria on their websites, we’ve conducted a review of policies from a sample of 8 plans with regional and national presence. Overall, policies appear to be consistent but there are many variations on specific criteria nuances.

The following figure provides a comparative summary of the selected policies (click on the image to enlarge it).



Sources:

Highmark Blue Shield. Forteo policy.

The Regence Group. Forteo policy.

Blue Cross Blue Shield of Michigan. Prior authorization/step therapy program.

BlueCross BlueShield of Alabama. Forteo Coverage Criteria.

Wellpoint, NextRx. Anthem National Drug Formulary.

Aetna. Clinical Policy Bulletin: Forteo.

Cigna. Forteo Coverage Policy.

Humana. Forteo Medical Coverage Policy.

[jacqueline.kostick]

Overall, these policies appear to be consistent with the evidence; however, there are a number of undefined areas and subtle differences in the treatment guideline recommendations issued by the national specialty organizations.

Specifically,

According to the American Association of Clinical Endocrinologists (AACE) 2003 update of guidelines for the management of postmenopausal osteoporosis, Forteo does not have the same high level of evidence for reduction of hip fractures as the bisphosphonates. AACE states that Forteo can be used in osteoporosis patients who have failed or been intolerant of previous osteoporosis therapy (specific criteria for failure or intolerance were not provided).

The North American Menopause Society (NAMS) guidelines (from 2006) state that Forteo should be reserved for patients at high risk of fracture, including those with a very low BMD (T-score less than -3.0) and with a previous vertebral fracture.

Sources:

American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) (2001 with selected updates from 2003) Available at the following link

North American Menopause Society (NAMS) position statement: Management of osteoporosis in postmenopausal (2006) Available at the following link

National Osteoporosis Foundation (NOF): Clinician's Guide to Prevention and Treatment of Osteoporosis (2008) Available at the following link

Eli Lilly and Co. Forteo (teriparatide injection) prescribing information. Indianapolis, IN; 2008 Feb. Prescribing information: Prescribing information

MacLaughlin EJ, et al. Management of age-related osteoporosis and prevention of associated fractures. Ther Clin Risk Manag. 2006 Sep: 281–295. Available at the following link