Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
celecoxib

Criteria Approval Period
1. Diagnosis of osteoarthritis
PLUS
trial of acetaminophen
PLUS
treatment failure or intolerance to at least one of the following: ASA-enteric, ibuprofen or naproxen
PLUS
treatment failure or intolerance to at least three of the following: diclofenac, diflunisal, fenoprofen, indomethacin, ketoprofen, salsalate, nabumetone, piroxicam, sulindac, tenoxicam, tiaprofenic, tolmetin or meloxicam.

OR

2. Diagnosis of rheumatoid arthritis or other inflammatory conditions
PLUS
treatment failure or intolerance to at least one of the following: ASA-enteric, ibuprofen, naproxen
PLUS
treatment failure or intolerance to at least three of the following: diclofenac, diflunisal, fenoprofen, flurbiprofen, indomethacin, ketoprofen, salsalate, nabumetone, piroxicam, sulindac, tenoxicam, tiaprofenic, tolmetin or meloxicam.

 Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Group 4 NSAID
  • Treatment failure or intolerance to the specific medications listed in the above criteria is required.
  • Treatment failure or intolerance to the following NSAIDs is not sufficient: ketorolac, mefenamic acid, diclofenac potassium, naproxen sodium and different formulations of the same NSAID.

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