COVERED USES:

FDA Approved Indications:

• Relief of signs and symptoms of ankylosing spondylitis,
• Juvenile rheumatoid arthritis in patients 2 years and older,
• Rheumatoid arthritis in adults
• Osteoarthritis,
• Management of acute pain in adults,
• Treatment of primary dysmenorrheal, and
• As an adjunct treatment of usual care in familial multiple polyposis syndrome.

Requests for a non-FDA approved ("off-label") indication requires the proposed indication be listed in either the American Hospital Formulary System (AHFS), USP-DI, or Drugdex and is considered subject to evaluation of the prescriber's medical rationale, formulary alternatives, the available published evidence-based research and whether the proposed use is determined to be experimental/investigational.

AGE RESTRICTIONS:

NA

PRESCRIBER RESTRICTIONS:

NA

REQUIRED MEDICAL INFORMATION:

For initiation of treatment, a prior authorization form and relevant chart notes documenting medical rationale are required and for continuation of therapy, ongoing documentation of successful response to the medication may be necessary.

CRITERIA:

Failure of two of the following NSAIDS: Diclofenac, Etodolac, Nabumetone, Meloxicam, or Sulindac.

EXCLUSION CRITERIA:

NA

COVERAGE DURATION:

Initial authorization and reauthorization will be approved for up to one year.