Limited coverage drugs – indomethacin

Generic name		indomethacin
Strength		25 mg, 50 mg
Form		capsule

Special Authority criteria	Approval period
For the treatment of patients who have a: Diagnosis of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout or lupus OR Treatment failure on optimal doses of, or intolerance to, all of the following: ibuprofen, naproxen, diclofenac AND either celecoxib or meloxicam.	Indefinite

Practitioner exemptions

Practitioners in the following specialty are not required to submit a Special Authority request form for coverage:

• Pediatrics
• Pediatric cardiology
• Pediatric general surgery
• Physical medicine and rehabilitation
• Rheumatology

Special notes

• Indomethacin suppositories are regular benefits.
• Treatment failure on or intolerance to the specific medications listed in the above criteria is required. Treatment failure on or intolerance to the following NSAIDs is not sufficient: ketorolac, mefenamic acid, diclofenac potassium, naproxen sodium.

Special Authority request form(s)

• Log in to eForms
• HLTH 5328 - General Special Authority Request (PDF, 656KB)