Limited coverage criteria – diflunisal

 

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Generic name	diflunisal
Strength & form	250 mg, 500 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	Indefinite
For the treatment of patients with treatment failure on optimal doses of, or intolerance to, all of the following: ibuprofen, naproxen, diclofenac AND either celecoxib or meloxicam	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. Treatment failure on or intolerance to the following NSAIDs is not sufficient: ketorolac, mefenamic acid, diclofenac potassium, naproxen sodium

Special Authority request form(s)

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