OBJECTIVES: To examine the association between teriparatide adherence and healthcare utilization and costs in “real world” U.S. hip fracture (HFx) patients. METHODS: A large U.S. administrative claims database was used to identify patients aged 50+ with an HFx between January 1, 2002-December 31, 2010 (first observed HFx = HFx index). All patients included had 6+ months of pre-HFx index continuous enrollment (baseline) and no baseline teriparatide, cancer, or Paget’s disease. Patients initiating teriparatide post-HFx index were followed from initiation (exposed period) until censoring at switch to bisphosphonates, disenrollment, 36 months post-HFx index, cancer, or Paget’s disease. Adherence was measured as the proportion of days covered (PDC) by teriparatide during the exposed period (teriparatide PDC). Outcomes were repeated HFx and per-patient per-month (PPPM) inpatient costs and number of inpatient admissions, outpatient costs, pharmacy costs, and total costs. Multivariable Generalized Linear Models examined the association between teriparatide PDC (≤0.5 ‘low,’ >0.5-≤0.8 ‘medium,’ >0.8 ‘high’) and the outcomes, adjusting for important patient characteristics. RESULTS: Study included 824 patients; mean age 75 years, 90% female; 29% low PDC; 27% medium PDC; 44% high PDC. In multivariable analyses, high adherence was significantly (all P<0.05) associated with increased PPPM pharmacy costs (low=$621; medium=$1,093; high=$1,572), but the lowest PPPM inpatient costs (low=$963; medium=$960; high=$629), number of inpatient admissions (incidence rate ratio vs. high=1.26 [low] and 1.28 [medium]), and outpatient costs (low=$1087; medium=$1068; high=$776). PPPM total costs differed significantly across the teriparatide PDC groups (all P<0.05) and were highest in the medium PDC group (low=$2599; medium=$3163; high=$2869). Too few repeated hip fractures (low=11; medium=6; high=2) occurred to complete multivariable analysis. CONCLUSIONS: Among HFx patients newly-initiating teriparatide, significantly increased pharmacy costs associated with greater teriparatide adherence were offset by significantly lower inpatient admissions as well as inpatient and outpatient costs.