Limited Coverage Drugs - Piroxicam 10 / 20 mg suppositories
|
Generic Name / Strength / Form |
|
|
piroxicam / 10mg, 20mg / suppositories |
| Special Authority Criteria | Approval Period |
| Treatment failure or intolerance to at least one other specified Non-Steroidal Anti-Inflammatory Drug (NSAID) suppository. |
Indefinite |
Practitioner Exemptions
- Practitioners in the following specialty are not required to submit a Special Authority request form for coverage: Rheumatology.
Special Notes
- NSAID suppository failure must be specified.
- Benefit NSAID suppositories include: acetylsalicylic acid (ASA), diclofenac, indomethacin, ketoprofen, naproxen.
