Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
meloxicam 7.5mg and 15mg

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

OR

2. Diagnosis of osteoarthritis
PLUS
trial of acetaminophen
PLUS
treatment failure or intolerance to at least one of the following: ASA-enteric, ibuprofen, naproxen
PLUS
at least three other NSAIDS from the following: ASA-enteric, naproxen, ibuprofen, diclofenac, diflunisal, fenoprofen, flurbiprofen, indomethacin, ketoprofen, salsalate, nabumetone, piroxicam, sulindac, tenoxicam, tiaprofenic, tolmetin.

 Indefinite

Practitioner Exemptions

  • Rheumatologists

Special Notes

  • Group 3 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, celecoxib and different formulations of the same NSAID.

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