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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.
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Last Revised: January 21, 2008
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