Prior Authorization Request Form for Teriparatide injection USFHP Pharmacy Prior Authorization Form To be completed by Requesting provider Drug Name: Strength: 7231 Parkway Drive, Suite 100, Hanover, MD 21076

Dosage/Frequency (SIG): Duration of Therapy: FAX Completed Form and Applicable Progress Notes to: (410) 424-4037 Questions? Contact the Pharmacy Dept at: (888) 819-1043, option 4 Clinical Documentation must accompany form in order for a determination to be made. Prior authorization expires after 24 months.

1B Step 3BPlease complete patient and physician information (please print):

2B1 Patient Name: Physician Name: Address: Address:

Sponsor ID # Phone #: Date of Birth: Secure Fax #:

4B Step 6BPlease complete the clinical assessment: 1. For te o is the Department of Defense's preferred 5B 2 (PTH) analog.  Acknow ledged The preferred product does not require prior Proceed to question 2 authorization. Please consider changing the prescription to the preferred product.

7B2. Has the patient tried and failed Forteo?  Yes  No Proceed to question 3 STOP Cov erage not approv ed

8B3. Is the patient greater than or equal to 18 years of  Yes  No age? Proceed to question 4 STOP Cov erage not approv ed

9B4. Is the requested medication prescribed for treatment  Yes  No of osteoporosis and not for prevention of Proceed to question osteoporosis? 5 STOP Cov erage not approv ed

10B5. What is the indication or diagnosis?  Postmenopausal female patient w ith osteoporosis - Proceed to question 6  Male patient w ith primary or hypogonadal osteoporosis - Proceed to question 6  Male or female patient w ith osteoporosis associated w ith sustained systemic glucocorticoid therapy (for example, more than 6 months use of greater than 7.5 mg/day of prednisone or equivalent) - Proceed to question 6  Other - STOP Cov erage not approv ed Prior Authorization Request Form for Teriparatide injection

11B6. Does the patient have a high risk for fracture due to  Yes  No history of osteoporotic fracture? Proceed to question 8 Proceed to question 7

12B - 13B7. Does the patient have multiple risk factors for  Yes  No fracture (for example, a history of vertebral fracture Proceed to question 8 or low-trauma fragility fracture of the hip, spine or STOP pelvis, distal forearm or proximal humerus)? Cov erage not approv ed

14B8. Does the patient have a documented bone mineral  Yes  No density (BMD) with T-score of -2.5 or w orse? Proceed to question 9 STOP Cov erage not approv ed

15B9. Is the patient able to take and  Yes  No supplements and will continue throughout therapy? Proceed to question 10 STOP Cov erage not approv ed

16B10. Has the patient tried and experienced an inadequate  Yes  No response to at least one formulary osteoporosis Proceed to question Proceed to question therapy (for example, alendronate, ibandronate)? 14 11

17B11. Has the patient had therapeutic failure with at least  Yes  No one formulary osteoporosis therapy (for example, Proceed to question Proceed to question alendronate, ibandronate)? 14 12

18B12. Is the patient intolerant to (unable to use or absorb)  Yes  No to at least one formulary osteoporosis therapy (for Proceed to question Proceed to question example, alendronate, ibandronate)? 14 13

19B13. Does the patient have contraindications to at least  Yes  No one formulary osteoporosis therapy (for example, Proceed to question 14 alendronate, ibandronate)? STOP Cov erage not approv ed

20B14. Does the patient have an increased risk for  Yes  No ? STOP Proceed to question 15 Cov erage not approv ed

21B15. Will the cumulative treatment w ith  Yes  No teriparatide/Bonsity, Tymlos, and/or Forteo exceed Sign and date below 24 months during the patient's lifetime? STOP Cov erage not approv ed

Step I certify the above is true to the best of my knowledge. Please sign and date: 3 Prescriber Signature Date

0B[05 August 2020] For Internal Use Only  Approved: Duration of Approval: month(s)  Denied: Authorized By:  Incomplete/Other: PA#: Date Faxed to MD: Date Decision Rendered: