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Limited Coverage Drugs - Special Authority Criteria
| Generic Name |
| piroxicam 10 mg, 20mg capsules |
| 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: ASA-enteric, naproxen, ibuprofen
PLUS
at least 3 other NSAIDS from the following list: ASA-enteric, naproxen, ibuprofen, diclofenac, diflunisal, fenoprofen, flurbiprofen, indomethacin, ketoprofen, salsalate, nabumetone, sulindac, tenoxicam, tiaprofenic, tolmetin.
|
Indefinite |
Practitioner Exemptions
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, meloxicam, rofecoxib, valdecoxib, 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 22, 2008
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