Non Steroidal Anti Inflammatory Drugs – Piroxicam

Generic Name

piroxicam

Strength

10 mg, 20mg
Form capsule

Special Authority Criteria

Approval Period

1. Diagnosis of rheumatoid or psoriatic arthritis, ankylosing spondylitis, gout or lupus.

OR

2. Diagnosis of osteoarthritis

PLUS

Trial of acetaminophen

PLUS

Treatment failure or intolerance to at least one of the following: ASA-enteric, ibuprofen, naproxen

PLUS

At least 3 other Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) from the following list: acetylsalicylic acid (ASA)-enteric, naproxen, ibuprofen, diclofenac, diflunisal, flurbiprofen, indomethacin, ketoprofen, nabumetone, sulindac, tenoxicam, tiaprofenic.

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

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

Special Authority Request Form