Limited coverage criteria – meloxicam

Last updated on March 19, 2025

Special Authority requests can now be submitted online. It's simple and quick!

Generic name		meloxicam
Strength & form		7.5 mg, 15 mg tablet

Special Authority criteria	Approval period
For the treatment of patients who have a: Diagnosis of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout or lupus OR Treatment failure on optimal doses of, or intolerance to, both ibuprofen and naproxen	Indefinite

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, both ibuprofen and naproxen

Indefinite

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

Treatment failure on, or intolerance to, the specific medications listed in the above criteria is required

Special Authority request form(s)

Log in to eForms
HLTH 5328 – General Special Authority request (PDF, 656KB)

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