Nonsteroidal Anti-inflammatory Drugs Coverage Policy

Initial Therapy Criteria (Product-specific)

General statement

The product(s) in the table below are considered medically necessary when the following are met:

Product-specific criteria detailed per listed formulation (see individual entries).

Employer Plans - Coxanto (oxaprozin) 300 mg capsule

Covered when ALL of the following are met:

There is documentation the individual has had an inadequate response, contraindication, or is intolerant to FIVE prescription-strength nonsteroidal anti-inflammatory drugs.FIVE

Employer Plans - diclofenac potassium 25 mg capsule or tablet (Zipsor/Lofena generics)

Covered when ALL of the following are met:

Individual has had an inadequate response, contraindication, or is intolerant to FIVE prescription-strength oral nonsteroidal anti-inflammatory drugs (excluding diclofenac).FIVE

Examples include: etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, indomethacin.

Employer Plans - fenoprofen (200 mg and 400 mg capsules) and Fenortho (fenoprofen 200 mg capsule) and Nalfon (fenoprofen calcium)

Covered when ALL of the following are met:

ALL of the following

Formulation-specific A: Individual has intolerance to fenoprofen 600 mg tablets.

Employer Plans - Indocin (indomethacin) 25 mg/5 mL oral suspension

Covered when BOTH of the following are met:

Individual has an inability to swallow indomethacin 25 mg or 50 mg capsules.

Inadequate response, contraindication or intolerance to ibuprofen 100 mg/5 mL oral suspension.

Employer Plans - Indocin (indomethacin) 50 mg suppository

Covered when BOTH of the following are met:

Individual has an inability to use indomethacin 25 mg or 50 mg capsules.

Individual has had an inadequate response, contraindication, or is intolerant to FOUR prescription-strength nonsteroidal anti-inflammatory drugs.FOUR

Employer Plans - indomethacin 20 mg capsule and Tivorbex (indomethacin) 20 mg and 40 mg capsule

Covered when BOTH of the following are met:

Individual is intolerant to indomethacin 25 mg or 50 mg capsules (for 20 mg capsule) OR has had an inadequate response or intolerance to indomethacin 25 mg or 50 mg capsules (for Tivorbex).

Individual has had an inadequate response, contraindication, or is intolerant to FOUR prescription-strength nonsteroidal anti-inflammatory drugs (excluding indomethacin).FOUR

Employer Plans - ketoprofen 25 mg capsule and Kiprofen (ketoprofen) 25 mg capsule

Covered when BOTH are met (ketoprofen 25 mg) or failure to FIVE unique NSAIDs (Kiprofen):

ANY of the following

ketoprofen 25 mg capsule: A. Individual is intolerant to ketoprofen 50 mg capsules. B. Individual has had an inadequate response, contraindication, or is intolerant to FOUR prescription-strength nonsteroidal anti-inflammatory drugs (excluding ketoprofen).FOUR
Kiprofen 25 mg capsule: Failure or intolerance to FIVE unique prescription-strength oral nonsteroidal anti-inflammatory drugs.FIVE
Examples include diclofenac, etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, indomethacin.

Employer Plans - mefenamic acid 250 mg capsule

Covered when ALL of the following are met:

Individual has had an inadequate response, contraindication, or is intolerant to FIVE prescription-strength nonsteroidal anti-inflammatory drugs (excluding mefenamic).FIVE

Examples include diclofenac, etodolac, flurbiprofen, ibuprofen, ketoprofen, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, indomethacin.

Employer Plans - meloxicam 5 mg and 10 mg capsule and Vivlodex (meloxicam) 5 mg and 10 mg

Covered when BOTH of the following are met:

Individual is intolerant to meloxicam 7.5 mg or 15 mg tablets.

Individual has had an inadequate response, contraindication, or is intolerant to FOUR prescription-strength nonsteroidal anti-inflammatory drugs (excluding meloxicam).FOUR

Employer Plans - meloxicam 7.5 mg/5 mL oral suspension

Covered when BOTH of the following are met:

Individual has an inability to swallow meloxicam 7.5 mg or 15 mg tablets.

Inadequate response, contraindication, or intolerance to ibuprofen 100 mg/5 mL oral suspension.

Employer Plans - Naprelan / Naproxen CR / Naproxen ER (various ER/CR strengths)

Covered when BOTH of the following are met:

Documentation the individual has had an inadequate response, contraindication, or is intolerant to naproxen 250 mg, 375 mg, or 500 mg immediate release tablets.

Documentation of inadequate response, contraindication, or intolerance to FOUR prescription-strength nonsteroidal anti-inflammatory drugs (excluding naproxen).FOUR

Employer Plans - Naprosyn / naproxen 125 mg/5 mL oral suspension

Covered when BOTH of the following are met:

Individual has an inability to swallow naproxen 250 mg, 375 mg, or 500 mg immediate release tablets.

Inadequate response, contraindication, or intolerance to ibuprofen 100 mg/5 mL oral suspension.

Employer Plans - oxaprozin 300 mg capsule

Covered when ALL of the following are met:

Documentation the individual has had an inadequate response, contraindication, or is intolerant to FIVE prescription-strength nonsteroidal anti-inflammatory drugs.FIVE

Employer Plans - Relafen (nabumetone) 500 mg and 750 mg, Relafen DS (1000 mg)

Relafen 500/750 mg: ALL of A, B, and C; Relafen DS 1000 mg: ALL of A, B, and C

A. Individual has had an inadequate response to nabumetone 500 mg tablets. B. Individual is intolerant to nabumetone 750 mg tablets. C. Individual has had an inadequate response, contraindication, or is intolerant to THREE prescription-strength nonsteroidal anti-inflammatory drugs (excluding nabumetone).THREE

Applies to Relafen and Relafen DS per strengths noted.

Employer Plans - Sprix (ketorolac) nasal solution

Covered when BOTH of the following are met:

Individual has had an intolerance or inability to swallow ketorolac 10 mg tablets.

Individual has had an inadequate response, contraindication, or is intolerant to FOUR prescription-strength nonsteroidal anti-inflammatory drugs (excluding ketorolac).FOUR

Employer Plans - Tolectin (tolmetin) 600 mg tablet

Covered when the following is met:

Trial of FIVE prescription-strength oral nonsteroidal anti-inflammatory drugs.FIVE

Employer Plans - Zipsor (diclofenac potassium) 25 mg capsule and Zorvolex (diclofenac) 18 mg and 35 mg capsule

Zipsor: ALL of A, B, and C; Zorvolex: BOTH A and B

Zipsor A. Individual has had an intolerance to diclofenac sodium 25 mg tablets. Zipsor B. Individual has had an intolerance to diclofenac sodium or potassium 50 mg tablets. Zipsor C. Individual has had an inadequate response, contraindication, or is intolerant to THREE prescription-strength nonsteroidal anti-inflammatory drugs (excluding diclofenac). Zorvolex A. Individual is intolerant to diclofenac 50 mg tablets or diclofenac 25 mg delayed-release tablets. Zorvolex B. Individual has had an inadequate response, contraindication, or is intolerant to FOUR prescription-strength nonsteroidal anti-inflammatory drugs (excluding diclofenac).THREE/FOUR

Apply A/B/C per product (Zipsor vs Zorvolex).

Individual and Family Plans - Coxanto / oxaprozin / Tolectin

Covered when specified trial/failure criteria are met (mirrors employer criteria):

Coxanto (oxaprozin 300 mg capsule): documentation of inadequate response, contraindication, or intolerance to FIVE prescription-strength NSAIDs.FIVE

oxaprozin 300 mg capsule: documentation of inadequate response, contraindication, or intolerance to FIVE prescription-strength NSAIDs.FIVE

Tolectin (tolmetin) 600 mg tablet: trial of FIVE prescription-strength oral NSAIDs.FIVE

Vimovo	naproxen/esomeprazole
Duexis	ibuprofen/famotidine
naproxen/esomeprazole
ibuprofen/famotidine

Term	Definition
Inadequate response	Documented lack of sufficient clinical benefit from prior prescription-strength NSAID therapy.
Intolerance	Documented adverse reaction preventing continued use of a prior NSAID.
Contraindication	Documented medical reason preventing use of a prior NSAID.

OpenPayer

Nonsteroidal Anti-inflammatory Drugs Coverage Policy

Coverage Summary & Scope

Initial Therapy Criteria (Product-specific)

Continuation / Reauthorization Criteria

Removals / Exclusions

Applicable Codes

Provider Actions & Authorization Requirements

Clinical Evidence & Guidance

Background & Definitions

Revision History

Coxanto 300 mg capsule	oxaprozin
diclofenac potassium 25 mg capsule	Zipsor generic
diclofenac potassium 25 mg tablet	Lofena generic
Fenoprofen 200 mg capsule
Fenoprofen 400 mg capsule
Fenortho (fenoprofen 200 mg capsule)
Indocin (indomethacin) 25 mg/5 mL oral suspension
Indocin (indomethacin) 50 mg suppository
indomethacin 20 mg capsule
ketoprofen 25 mg capsule