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 osteoporosis parathyroid hormone (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 calcium and vitamin D 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 osteosarcoma? 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: .