Limited Coverage Drugs - indomethacin

Generic Name



25 mg, 50 mg



Special Authority Criteria

Approval Period

For the treatment of patients who have a:

  • Diagnosis of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout or lupus


  • Treatment failure on optimal doses of, or intolerance to, all of the following: ibuprofen, naproxen, diclofenac AND either celecoxib or meloxicam.


Practitioner Exemptions

Practitioners in the following specialty are not required to submit a Special Authority request form for coverage:

  • Pediatrics
  • Pediatric cardiology
  • Pediatric general surgery
  • Physical medicine and rehabilitation
  • Rheumatology

Special Notes

  • Indomethacin suppositories are regular benefits.
  • Treatment failure on or intolerance to the specific medications listed in the above criteria is required. Treatment failure on or intolerance to the following NSAIDs is not sufficient: ketorolac, mefenamic acid, diclofenac potassium, naproxen sodium.

Special Authority Request Form(s)