Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form

raloxifene

Criteria Approval Period

Clinical or radiographically-documented fracture due to osteoporosis

AND

  1. Demonstrated intolerable side effects to a minimum 1 month trial of oral bisphosphonates, alendronate or risedronate;

OR

  1. Unsatisfactory clinical response, defined as a new fragility fracture after 1 year adherence to alendronate or alendronate plus cholecalciferol or risedronate therapy.

Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Clinical fracture is defined as a symptomatic (painful) fracture.
  • Radiographically-documented fracture is defined as a fracture identified by X-ray (e.g., vertebral compression fracture). This may be asymptomatic.
  • Intolerable side effects are defined as esophageal ulceration, erosion or stricture or lower gastrointestinal symptoms severe enough to cause discontinuation of bisphosphonates.
  • Fragility fracture is defined as a fracture that occurs as a result of minimal trauma (e.g., fall from a standing height or less).

Special Authority Request Form(s)

Online Forms (PDF, 523KB)
Click on the link to complete a special authority request form.