Limited coverage criteria – ketoprofen SR

 

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Generic name		ketoprofen
Strength & form		200 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, 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)