Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form



Approval Period

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


2. Diagnosis of osteoarthritis
trial of acetaminophen
treatment failure or intolerance to at least one of: ASA-enteric, naproxen, ibuprofen
at least 3 other NSAIDS from the following list: ASA-enteric, naproxen, ibuprofen, diclofenac, diflunisal, fenoprofen, flurbiprofen, indomethacin, ketoprofen, salsalate, piroxicam, sulindac, tenoxicam, tiaprofenic, tolmetin.


Practitioner Exemptions

  • Rheumatologists

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, meloxicam and different formulations of the same NSAID.

Special Authority Request Form(s)

Online Forms (PDF, 524KB)
Click on the link to complete a special authority request form.