Certificate of Medical Necessity

Certificate of Medical Necessity Teriparatide (Forteo®) J3110 Please fax completed CMN forms and other required documentation (i.e., physician history and physical; physician progress notes; with documentation of conservative treatment including prior medications used; treatment plan including narrative). Statewide Fax Number: 904-905-9849

SECTION A Provider Information Name BCBSF Number National Provider Identifier (NPI) Street Address City State Zip Telephone Number Fax Number Contact Name Member Information Last Name First Name Member/Contract Number (alpha and numeric) Date of Birth

SECTION B Please provide diagnosis code and description. ICD9 code ______Description ______Is medication being administered by provider or self administered by patient ? Is patient picking up medication at a retail pharmacy? Yes No N/A Is provider buying the medication and billing BCBSF directly? Yes No N/A Is provider obtaining medication from Caremark for drug replacement? Yes No N/A Is this the initial request or continuation of therapy . If continuation, what date was therapy initiated? ______If continuation, has patient demonstrated a beneficial response to medication? ______Please provide prescribed dosage (milligrams, administration route, frequency): ______

SECTION C Please complete based upon patient’s condition: Check Response Is member a postmenopausal woman with osteoporosis who is at high risk for fracture? Yes No A. Is member 18 years of age or older? Yes No B. Has failed or is intolerant of previous bisphosphonate therapy (e.g., Fosamax®, Boniva®, etc.) or a selective Yes No estrogen receptor modulator, based on physician assessment. Which medication was previously used? ______Is member a man with primary or hypogonadal osteoporosis who is at high risk for fracture? Yes No A. Is member 18 years of age or older? Yes No B. Has failed or is intolerant of previous bisphosphonate therapy (e.g., Fosamax®, Boniva®, etc.), based on physician Yes No assessment. Which medication was previously used? ______Is member a man or woman with sustained systemic glucocorticoid-induced osteoporosis at high risk for fracture? Yes No A. Is member 18 years of age or older? Yes No B. Has failed or is intolerant of previous bisphosphonate therapy (e.g., Fosamax®, Boniva®, etc.), based on physician Yes No assessment. Which medication was previously used? ______Note: Teriparatide therapy is limited to 2 years (24 months)

Comments:______

of 1 Effective: 04/06/11