Limited Coverage Drugs - Special Authority Criteria

Generic Name
Piroxicam 10mg, 20mg suppository

Criteria Approval Period
Treatment failure or intolerance to at least one other specified Non Steroidal Anti-inflammatory (NSAID) suppository. Indefinite

Practitioner Exemptions

  • Rheumatologists

Special Notes

  • NSAID suppository failure must be specified
  • Benefit NSAID Suppositories: acetylsalicylic acid (ASA), diclofenac, indomethacin, ketoprofen, or naproxen

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