Limited coverage criteria – piroxicam

Last updated on March 21, 2025

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

Generic name		piroxicam
Strength & form		10 mg/20 mg capsule

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

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

Indefinite

Practitioner exemptions

Practitioners in the following specialties are not required to submit a Special Authority request 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)

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