OBJECTIVES: To evaluate the cost-effectiveness of first-line treatments of osteoporotic fractures in Chinese women. METHODS: A previously documented and validated osteoporosis state-transition microsimulation model was used, incorporating major clinical outcomes of osteoporosis. Simulated patients’ evolving fracture and treatment histories were monitored using tracker variables with a one-year simulation cycle length and lifetime horizon. Treatments included were calcium and vitamin D supplements, calcitonin, raloxifene, alphacalcidol, alendronate and zoledronic acid, all of which are first-line treatments in China. Patients in the treatment group were assumed to receive medications when they had an osteoporotic fracture, while “no treatment” was assumed as the comparator. The initial simulated population was women aged 50 years without a history of osteoporotic fracture. The study was conducted from the Chinese healthcare payer’s perspective. The study design followed the Chinese Guideline for Pharmacoeconomic Evaluations. Costs and effectiveness were presented in 2015 USD and quality-adjusted life years (QALYs) respectively. Willingness-to-pay (WTP) threshold was set at USD 20,000/QALY gained. Extensive uni- and multivariable sensitivity analysis was performed. RESULTS: Lifetime costs and effectiveness for “no treatment” were USD 14,054 and 12.452 QALYs. Lifetime costs for treatment with calcium and vitamin D supplements, calcitonin, raloxifene, alphacalcidol, alendronate and zoledronic acid were USD 14,058, 14,115, 14,633, 14,481, 14,571 and 17,007 respectively. Lifetime effectiveness were 12.457, 12.494, 12.513, 12.579, 12.580 and 13.049 QALYs respectively. Among all non-dominated treatments (calcium and vitamin D supplements, calcitonin, alphacaldidol and zoledronic acid), zoledronic acid was the most cost-effective with an incremental cost of USD 5,367/QALY gained compared with alphacalcidol. The results were generally robust within a wide range of one-way sensitivity analyses.  CONCLUSIONS: Until now, economic evidence to support the reimbursement policy of osteoporosis treatments in China has been lacking. Our study has demonstrated that all first-line treatments are cost-effective compared with no treatment, while zoledronic acid is the most cost-effective in Chinese women.