Limited coverage criteria – naproxen SR

Last updated on March 19, 2025

 

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Generic name

naproxen

Strength & form

750 mg, sustained-release 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

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)