Non Steroidal Anti Inflammatory Drugs - Special Authority Criteria

Generic Name / Strength / Form
ketoprofen - regular release and enteric coated forms

Criteria Approval Period
1. Diagnosis of rheumatoid or psoriatic arthritis or ankylosing spondylitis or gout or lupus.

OR

2. Treatment failure or intolerance to at least one of the following: ASA-enteric, naproxen, or ibuprofen.

 Indefinite

Practitioner Exemptions

  • Rheumatologists

Special Notes

  • Group 2 NSAID
  • Coverage for ketoprofen 150mg and 200mg sustained release products are subject to further limitations. Full coverage is only provided for individuals who have documented breakthrough symptoms while on the regular release form for a trial period. Full coverage is not provided for dosage convenience.

Online Form (PDF)
Click on the link to complete a special authority request form.