Tier 1 products are covered with no authorization necessary.
Tier 2 authorization criteria:
- Previous use of at least two Tier 1 NSAIDs (from different product lines) plus a PPI within the last 120 days, or
- For those with prior GI bleed who must have an NSAIDs, a Tier 2 product may be approved (Celebrex should also be taken with a PPI)
Special PA approval criteria:
- A unique indication for which a Tier-1 or Tier-2 medication is not appropriate, such as the diagnosis of gout for indomethacin; or
- Previous use of at least two Tier-1 NSAID products (from different product lines); and
- A patient-specific, clinically significant reason why a special formulation is needed over a Tier-1 product.
- Additionally, use of Tivorbex™ will require a patient-specific, clinically significant reason why member cannot use other available generic indomethacin products.
- Additionally, use of Celebrex (celecoxib) 400mg capsules will require a diagnosis of Familial Adenomatous Polyposis (FAP) and a patient-specific, clinically significant reason why the member cannot use two celecoxib 200mg capsules to achieve a 400mg dose.
Meloxicam suspension for members older than 7 years of age will require a prior authorization. A prior authorization request can be submitted for members older than 7 years of age requiring meloxicam suspension. A reason why the member needs the liquid formulation and cannot use the oral tablet formulation should be provided with the prior authorization request.
Anjeso® (Meloxicam Injection) Approval Criteria:
- An FDA approved diagnosis of management of moderate-to-severe pain, alone or in combination with non-nonsteroidal anti-inflammatory drug (NSAID) analgesics; and
- Member must be 18 years of age or older; and
- Prescriber must verify member will be well hydrated before Anjeso® administration to reduce the risk of renal toxicity; and
- Anjeso® should be used for the shortest duration consistent with individual patient treatment goals; and
- A patient-specific, clinically significant reason the member cannot use oral meloxicam tablets or other Tier-1 NSAIDs must be provided; and
- A quantity limit of 3 vials per 3 days will apply; and
- For consideration of a longer duration of use, a patient-specific, clinically significant reason why the member cannot transition to an oral Tier-1 NSAID must be provided, along with the anticipated duration of treatment.
NOTE: In order for previously utilized Tier 1 medications to count as trials toward a Tier 2 authorization, the member's NSAID therapy must have been continuous. Dates and dosing information for Tier 1 trials must be included on petition for authorization. Trials with OTC formulations of Tier 1 products must be dosed at full prescription strength.
Prior Authorization form
- celecoxib (Celebrex®) 50mg,100mg and 200mg caps
- diclofenac epolamine (Flector®)
- diclofenac sodium (Voltaren®) 50mg and 75mg
- diclofenac sodium gel (Voltaren Gel®)
- etodolac (Lodine®) 400mg and 500mg tabs
- flurbiprofen (Ansaid®)
- ibuprofen (Motrin®)
- meloxicam (Mobic®)
- nabumetone (Relafen®)
- naproxen (Naprosyn®)
- naproxen EC (Naprosyn EC®)
- sulindac (Clinoril®)
- diclofenac ER (Voltaren XR®)
- diclofenac sodium/misoprostol (Arthrotec®)
- diclofenac potassium (Cataflam®)
- diclofenac sodium (Voltaren®) 25mg tabs
- etodolac (Lodine®) 200mg and 300mg cap
- etodolac ER (Lodine XL®)
- naproxen sodium (Anaprox®) 275mg and 550mg tabs
- oxaprozin (Daypro®)
- piroxicam (Feldene®)
- tolmetin (Tolectin®)
- celecoxib (Celebrex®) 400mg caps
- diclofenac (Zorvolex™)
- diclofenac epolamine (Licart™) topical system
- diclofenac potassium (Zipsor®, Cambia®)
- diclofenac injection (Dyloject™)
- diclofenac sodium drops (Pennsaid®)
- fenoprofen (Nalfon®)
- ibuprofen injection (Caldolor®)
- ibuprofen/famotidine (Duexis®)
- indomethacin (Tivorbex™)
- indomethacin susp and er caps (Indocin®)
- ketoprofen (Orudis®) caps
- ketoprofen ER (Oruvail®)
- ketorolac tromethamine (Sprix®) nasal spray
- mefanamic acid (Ponstel®)
- meclofenamate (Meclomen®)
- meloxicam (Anjeso®) inj
- meloxicam capsules (Vivlodex™)
- meloxicam ODT (Qmiiz™ ODT)
- nabumetone 1,000mg (Relafen™ DS)
- naproxen sodium (Naprelan®)
- naproxen/esomeprazole (Vimovo®)
caps = capsules; ER = extended-release; EC = enteric-coated; inj = injection; ODT = orally disintegrating tablet; PA = prior authorization; susp = suspension; tabs = tablets
Tier structure based on supplemental rebate participation and/or National Average Drug Acquisition Costs (NADAC), Wholesale Acquisition Costs (WAC), or State Maximum Allowable Costs (SMAC).
*Naproxen oral suspension is available without prior authorization for members 12 years of age and younger. Members older than 12 years of age will require a reason why a special formulation product is needed in place of the regular tablet formulation.