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.


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.

Special Authority Request Form