Limited Coverage Drugs – Celecoxib

Generic Name                                                 

celecoxib

Strength

100 mg, 200 mg
Form  capsule

Special Authority Criteria

Approval Period

1. For the treatment of patients:

With rheumatoid arthritis or ankylosing spondilitis or other inflammatory conditions

PLUS

Who are considered high risk for NSAID (Non Steroidal Anti Inflammatory Drugs) gastrointestinal toxicity AND have one or more of the following risk factors:

  • History of previous complicated GI ulcers (strictures/perforations)
  • Previous history of peptic ulcer disease with or without complications AND concomitant use of oral anticoagulants
  • History of GI bleed

PLUS

Who have experienced treatment failure or intolerance to two or more prescription NSAIDs.

Indefinite

 

OR
2. For the treatment of patients:

With Osteoarthritis

PLUS

Who are taking acetaminophen

PLUS

Who are considered high risk for NSAID gastrointestinal toxicity AND have one or more of the following risk factors:

  • History of previous complicated GI ulcers (strictures/perforations)
  • Previous history of peptic ulcer disease with or without complications AND concomitant use of oral anticoagulants
  • History of GI bleed

PLUS

Who have experienced treatment failure or intolerance to two or more prescription NSAIDs.

Indefinite

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

  • None

Special Authority Request Form(s)