Limited coverage drugs – raloxifene

Generic name / strength / form
raloxifene - all strengths and forms

Criteria	Approval period
Clinical or radiographically documented fracture due to osteoporosis AND demonstrated intolerable side effects to a minimum 1 month trial of oral bisphosphonates, alendronate or risedronate OR 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

Definitions for the above criteria:

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

Special Authority requests

• Log in to eForms​
• HLTH 5328 Special Authority Request form (PDF, 523KB)