raloxifene — Blue Cross Blue Shield of Kansas

Initial criteria

• The requested breast cancer primary prevention agent is covered under the pharmacy benefit or has been approved through the coverage exception process
• There is support that the requested breast cancer primary prevention agent is medically necessary
• The requested agent is tamoxifen, raloxifene, or an aromatase inhibitor (anastrozole, exemestane, letrozole)
• The patient age ≥ 35 years
• The agent is requested for the primary prevention of breast cancer
• ONE of the following: (A) The plan has not implemented a sex requirement OR (B) The plan has implemented a sex requirement AND ONE of the following: (1) The patient’s sex is female OR (2) The requested agent is medically appropriate for the patient’s sex

Approval duration

12 months