Non Sterioidal Anti Inflamatory Drugs - Sulindac

Generic Name

sulindac

Strength

150 mg, 200 mg
Form tablet

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, piroxicam, tenoxicam, tiaprofenic, tolmetin.

Indefinite

Practitioner Exemptions

  • Practitioners in the following specialty are not required to submit a Special Authority request form for coverage:
    • Paediatrics
    • Paediatric Cardiology
    • Paediatric General Surgery
    • Physical Medicine and Rehabilitation
    • Rheumatology

Special Notes

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, meloxicam, celecoxib and different formulations of the same NSAID.

Special Authority Request Form(s)