CommercialPrior AuthMedium impact
Evista (raloxifene) (Revised)
Humana·Endocrinology, Rheumatology, Oncology +2 more·Commercial
Effective date
Mar 27, 2024
We identified it
Jun 25, 2026
Summary
Humana revised its Evista (raloxifene) pharmacy coverage policy effective March 27, 2024. This is a step therapy policy requiring members to have prior treatment with or documented intolerance to at least one of the following agents (raloxifene, alendronate, ibandronate, or tamoxifen) before Evista coverage is approved. The policy includes important contraindications (active/past venous thromboembolism) and warnings (increased stroke risk in specific populations, not recommended for premenopausal women or cardiovascular prevention).
Action Required
By March 27, 2024: Billing team must implement step therapy requirements in claims processing system. (1) Update authorization rules to require documentation of prior treatment failure or intolerance to ONE of: raloxifene, alendronate, ibandronate, or tamoxifen before approving Evista coverage. (2) Front desk and clinical staff must add to patient intake/authorization forms: contraindication screening for active or past venous thromboembolism history. (3) Claims submitted for Evista without evidence of step therapy failure will be denied. (4) Verify current policy version at http://apps.humana.com/tad/tad_new/home.aspx before processing claims—do not rely on printed copies. (5) Educate providers that Evista is contraindicated in patients with history of DVT/PE/retinal vein thrombosis and is not recommended for premenopausal women or cardiovascular disease prevention.