Non Sterioidal Anti Inflamatory Drugs - Meloxicam

Generic Name

meloxicam

Strength

7.5 mg and 15 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 the following: ASA-enteric, ibuprofen, naproxen
 

PLUS

at least three other NSAIDS from the following: ASA-enteric, naproxen, ibuprofen, diclofenac, diflunisal, fenoprofen, flurbiprofen, indomethacin, ketoprofen, salsalate, nabumetone, piroxicam, sulindac, 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

  • 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 and different formulations of the same NSAID.

Special Authority Request Form(s)