Risk factors for development of calciphylaxis include underlying autoimmune disease, kidney failure, and concomitant warfarin or systemic corticosteroid use. This can result in taking the wrong dose of FORTEO. Please confirm below. PP-TE-US-1102 01/2021 ©Lilly USA, LLC 2021. Avoid use in patients with increased baseline risk of osteosarcoma including patients with open epiphyses (pediatric and young adult patients), metabolic bone diseases including Paget’s disease of the bone, bone metastases or history of skeletal malignancies, prior external beam or implant radiation therapy involving the skeleton, and hereditary disorders predisposing to osteosarcoma. For more information about Lilly’s privacy practice and to manage third-party preferences, click here. Patients may also call 1-800-545-6962 to request an application. It is not known whether teriparatide is excreted in human milk, affects human milk production, or has effects on the breastfed infant. This website uses cookies and other technologies to personalize content and ads on this and other websites and provide social media features. Card activation required. If FORTEO-treated patients have pre-existing hypercalciuria or suspected/known active urolithiasis, consider measuring urinary calcium excretion. The link you clicked on will take you to a site maintained by a third party, which is solely responsible for its content. Lilly USA, LLC is not responsible for the privacy policy of any third-party websites. This drug enables treatment of osteoporosis that may have caused by menopausal conditions, steroid usage or gonadal failure. Do NOT send it to RxResource. The FORTEO delivery device has enough medicine for 28 days. For more information, ask your healthcare provider or pharmacist. Pediatric UseThe safety and effectiveness of FORTEO have not been established in pediatric patients. Please select how you would like to receive your FORTEO co-pay card. Information and injection training. Once you fill out your application, send it to the address on the application. Please confirm below. Frequently Asked Questions. • Your FORTEO pen contains a cartridge, marked with lines and numbers to give you an idea of how much FORTEO is left in the pen. PP-TE-US-1102 01/2021 ©Lilly USA, LLC 2021. By accepting this offer, you agree that if you are required to do so under the terms of your insurance coverage for this prescription or are otherwise required to do so by law, you should notify your insurance carrier of your redemption of this Card. *Fora complete listing see Dosage Forms, Composition and Packaging section. Patient cannot use the card past 24 months of therapy. This site is intended for use by US healthcare professionals only. 3. Then your card will need to be activated below. You can enroll your patients online or by calling 1-866-4-FORTEO (1-866-436-7836), 8 am-10 pm ET (M-F). This Card is not health insurance. The link you clicked on will take you to a site maintained by a third party, which is solely responsible for its content. Available only in the US and Puerto Rico for residents of the US and Puerto Rico. These are not all the possible side effects of FORTEO. Your email address will not be saved or stored. In short-term clinical pharmacology studies of FORTEO in healthy volunteers, transient episodes of symptomatic orthostatic hypotension were observed in 5% of volunteers. (sub-q ) This is following a non union of the fibula from a surgery February 21st. Indications and Important Safety Information. Store the FORTEO delivery device with the white cap on. Side effects The FDA-approved label for Forteo lists common side effects including nausea and pain, especially joint pain. Pull off the paper tab from the outer needle shield and throw the paper tab away. Indications and Important Safety Information, Sorry, there was a problem sending your card(s). This offer is invalid for patients without commercial drug insurance or whose prescription claims for FORTEO are eligible to be reimbursed, in whole or in part, by any governmental program, including, without limitation, Medicaid, Medicare, Medicare Part D, Medigap, DoD, VA, TRICARE®/CHAMPUS, or any state patient or pharmaceutical assistance program. FORTEO may cause serious side effects, including: Bone cancer (osteosarcoma): Tell your healthcare provider right away if you have pain in your bones, pain in any areas of your body that does not go away, or any new or unusual lumps or swelling under your skin that is tender to touch. FORTEO CONNECT PATIENT SUPPORT PROGRAM Telephone: 1-866-4-FORTEO (1-866-436-7836) Fax: 1-866-436-7830 ... Additional information or forms may be needed and a FOR TEO Connect Support Specialist will contact your office with any additional requirements. This website uses cookies and other technologies to personalize content and ads on this and other websites and provide social media features. I went directly to Lilly, and qualified for pro bono meds for 2 years, the limit of tx on Forteo. Mail: 1) this COMPLETED application PLUS your prescriptions for FORTEO and injection supplies 2) a COPY of the first page of your most recent tax return, or, if no tax form exists, provide a COPY of other proof of income (for example, an SSA-1099) 3) ATTACH VALID PRESCRIPTIONS for both FORTEO and injection supplies FORTEO is a prescription medicine used to treat postmenopausal women who have osteoporosis who are at high risk for having broken bones (fractures) or who cannot use other osteoporosis treatments. Lilly USA, LLC does not control, influence, or endorse this site, and the opinions, claims, or comments expressed on this site should not be attributed to Lilly USA, LLC. Forteo® Enrollment Form Fax Referral To: 1-800- 323 -2445 Phone: 1 -800 -237- 2767 Email Referral To: customerservicefax@caremark.com . FORTEO® is a registered trademark owned and licensed by Eli Lilly and Company, its subsidiaries, and affiliates. Indications and Important Safety Information. Click “Continue” to leave site or “Return to forteo.com” to close this window and return to forteo.com. ; Forteo can lessen the number of fractures of the spine and other bones in postmenopausal women with osteoporosis. Forteo is a prescription medicine that is like a hormone made by the bodycalled parathyroid hormone or PTH. Please answer the following questions and fax this form to the number listed above. During drug testing, the medicine in FORTEO caused some rats to develop a bone cancer called osteosarcoma. Fax signed forms to CVS/Caremark at 1-855-633-7673. Do not let your FORTEO pen freeze. Patient is responsible for any applicable taxes, fees, or amounts exceeding monthly or annual caps. Select from the options below to see if you are eligible for the FORTEO Co-pay Card. This offer may be terminated, rescinded, revoked or amended by Lilly USA, LLC at any time without notice. Risk of Urolithiasis: Consider the risks and benefits in patients with active or recent urolithiasis because of risk of exacerbation. It is set to give a 20-microgram dose of medicine each day. Has anyone ever used Forteo? Attach the capped needle to the end of the pen by pushing it on and turning it clockwise (to the right). Osteosarcoma: Osteosarcoma has been reported in patients treated with FORTEO in the post marketing setting; however, an increased risk of osteosarcoma has not been observed in observational studies in humans. • Use of FORTEO for more than 2years during a patient’s lifetime should only be considered if a patient remains at or has returned to having ahigh risk for fracture(2.3)-----DOSAGE FORMS AND STRENGTHS-----Injection: 620 mcg/2.48 mL (250 mcg/mL) in a single-patient-use By using the FORTEO Co-pay (“Card”), you attest that you meet the eligibility criteria, agree to and will comply with the terms and conditions described below: Offer good until 12/31/2021. Phone: 1-855-240-0535 . FORTEO should be administered initially under circumstances in which the patient can sit or lie down if symptoms of orthostatic hypotension occur [see Warnings and Precautions ]. FORTEO is contraindicated in patients with hypersensitivity to teriparatide or to any of its excipients. Additional information or forms may be needed and a FORTEO Connect Support Specialist will contact your office with any additional requirements. Any brands other than FORTEO are trademarks of their respective owners and are not trademarks of Eli Lilly and Company. Increased calcium in your blood. Who qualifies for the Lilly Cares Program? I am using Forteo and a magnetic bone growth stimulator. Hypercalcaemia. The information contained in this section of forteo.com is intended for US Healthcare providers. See the “Medication Guide” for complete storage information. 46 . I am injecting tiny amounts daily into my abdomen. Hi-- When you say Medicare, I assume it is Medicare Part D, administered by an insurance company like Blue Cross, etc? FORTEO may cause serious side effects, including: Bone cancer (osteosarcoma): Tell your healthcare provider right away if you have pain in your bones, pain in any areas of your body that does not go away, or any new or unusual lumps or swelling under your skin that is tender to touch. (sub-q ) This is following a non union of the fibula from a surgery February 21st. Consent form. Prescription Information (for Insurance Investigation only) ℞ Medication: FORTEO® (teriparatide [rDNA origin] injection), 2.4-mL delivery device, NDC 0002-8400-01 What is Forteo and what is it used for? Before you try to inject FORTEO yourself, a healthcare provider should teach you how to use the FORTEO delivery device to give your injection the right way. You are encouraged to report side effects of prescription drugs to the Food and Drug Administration (FDA). ©Lilly USA, LLC 2021. Forteo FCHP 4/2013- CVS Caremark Specialty Pharmacy 2211 Sanders Road NBT - 6 Northbrook, IL 60062 Phone: 1-866-814- 5506 Fax: 1 -866-249- 6155 www.caremark.com Your email address will not be saved or stored. Forteo may help to form new bone,increase bone mineral density and bone strength. CVS Caremark Specialty Programs 2969 Mapunapuna Place Honolulu, HI 96819 Phone: 1-808-254-4414 Fax: 1-866-237- 5512 www.caremark.com FORTEO can lessen the chance of broken bones (fractures) in the spine and other bones in postmenopausal women with osteoporosis. If you have questions about Forteo, please contact Eli Lilly and Company directly or talk to your doctor. This Card is not health insurance. FORTEO is a sterile, colourless, clear, isotonic solution in prefilled pens. Use of Forteo is restricted to 24 months lifetime duration. If you click "I Disagree" you can still use this website. Prior Authorization Prescriber Fax Form
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