ModifiedCignaPolicy IP0457

Nonsteroidal Anti-inflammatory Drugs Coverage Policy

Defines medical necessity, initial and reauthorization criteria, and authorization durations for multiple branded and generic NSAID products for Cigna employer group and individual/family plans, including specific failure/intolerance requirements to other NSAIDs and formulation-specific criteria.

Policy Summary

PayerCigna

PolicyNonsteroidal Anti-inflammatory Drugs Coverage Policy

Policy CodePolicy IP0457

Change TypeRemoved specific combination products

Effective DateJul 15, 2025

Next Review Date

Key ActionProviders must submit evidence of prior medication trials or documented intolerance/contraindication per product-specific criteria (e.g., trials of FOUR or FIVE other prescription-strength NSAIDs or inability to swallow specific formulations).

SourceLink

POLICY UPDATE CHANGES

Removed Vimovo (naproxen/esomeprazole), Duexis (ibuprofen/famotidine), and ibuprofen/famotidine from policy.

~40Listed NSAID products

3Authorization duration (months)

3/4/5Typical prior-trial thresholds (3/4/5)

Coverage Summary & Scope

This policy applies to Cigna employer group and Individual & Family plans and defines medical necessity, initial and reauthorization criteria, and authorization durations for multiple branded and generic NSAID products. Coverage stance: covered_with_criteria — many NSAID products require prior authorization and documentation of prior trials, intolerances, or contraindications per product-specific criteria.

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The policy supports medical necessity review for numerous NSAID products and emphasizes that NSAIDs generally have similar clinical efficacy at equipotent doses, so product choice is guided by individual response and safety. All NSAID products carry Boxed Warnings for cardiovascular (CV) and gastrointestinal (GI) risks and safe use with the lowest effective dose for the shortest duration is recommended. The policy cites guidelines and safety resources including ACR/Arthritis Foundation (2019), EULAR (2018), OARSI (2019), and the AGS Beers Criteria (2023) to support safe-use recommendations.

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

Continuation / Reauthorization Criteria

Reauthorization Criteria

Continued use is medically necessary when:

Initial criteria are met AND there is documentation of beneficial response.

Documentation Required

Reauthorization requires beneficial response

Reauthorization requires that initial criteria are still met and there is documentation of beneficial clinical response to the NSAID.

Document beneficial clinical response at reauthorization; initial product-specific criteria must still be met.

Removals / Exclusions

Material change: per the Selected Revision Date 7/15/2025, the following combination products were removed from the policy and are no longer listed as covered: Vimovo (naproxen/esomeprazole), Duexis (ibuprofen/famotidine), and the generic listings for naproxen/esomeprazole and ibuprofen/famotidine.

These products were removed from coverage per the policy revision effective 7/15/2025 as documented in the revision details.

Applicable Codes

Covered drugs (listed by name, no J/HCPCS/NDC codes provided in document)mixedCovered

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

1–10 of 41

1/5

Removed from policy (per revision 7/15/2025)mixedNot Covered

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

Denial Risk

Claims denied without covered diagnosis/codes

Claims submitted without covered diagnosis or procedure codes per this policy will be denied as not covered. Providers must use the most appropriate codes as of the date of submission.

Use the most appropriate diagnosis/procedure codes as of the date of submission to avoid denial.

Provider Actions & Authorization Requirements

Prior Authorization

Prior authorization required per product-specific criteria

Coverage requires documentation of prior trials, intolerances, or contraindications per the listed product-specific criteria. Providers must submit evidence of prior medication trials or documented intolerance/contraindication when requesting authorization.

Common trial thresholds for quick reference: failure/intolerance/contraindication to FOUR prescription-strength NSAIDs
Higher threshold used for some products: FIVE prescription-strength NSAIDs

Documentation Required

Document inability to swallow or intolerance when applicable

For liquid or suppository formulations, document inability to swallow tablets or inability to use other formulations as specified (for example, inability to swallow 25 mg or 50 mg indomethacin capsules for the indomethacin suspension or suppository).

Denial Risk

Claims denied without covered diagnosis/codes

Claims submitted without covered diagnosis or procedure codes per this policy will be denied as not covered; providers must use the most appropriate codes as of the date of submission.

Documentation Required

Reauthorization requires beneficial response

Reauthorization requires that initial criteria are still met and there is documentation of beneficial clinical response to the NSAID.

At reauthorization, document beneficial clinical response and confirm that initial product-specific criteria continue to be met.

Clinical Evidence & Guidance

Evidence and background references: Facts and Comparisons Online was last updated September 1, 2023. Relevant guidelines cited in the policy include ACR/Arthritis Foundation 2019, EULAR 2018, OARSI 2019, and the AGS Beers Criteria 2023.

The policy notes that NSAID products generally have similar clinical efficacy when given at equipotent doses, but individual responses vary. All NSAID products include Boxed Warnings for CV and GI risks. The guidance emphasizes safe use and employing the lowest effective dose for the shortest duration consistent with guideline recommendations.

Background & Definitions

Rationale and policy emphasis: the policy supports medical necessity review across numerous NSAID products to ensure appropriate use based on prior trials, intolerance, or contraindications to alternative prescription-strength NSAIDs and formulation-specific needs (e.g., inability to swallow tablets).

Safety is a core rationale: NSAIDs carry CV and GI Boxed Warnings and the policy aligns with guideline recommendations (ACR/Arthritis Foundation 2019; EULAR 2018; OARSI 2019) and the AGS Beers Criteria (2023) to promote cautious use, selection of topical versus oral agents where appropriate, and minimizing risk by using the lowest effective dose for the shortest necessary duration.

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.

Revision History

2025-07-15revisionLatest

Selected Revision Date 7/15/2025: removed combination products from the policy — Vimovo (naproxen/esomeprazole), Duexis (ibuprofen/famotidine), and ibuprofen/famotidine were removed from coverage per the revision details.

Policy Summary

PayerCigna

PolicyNonsteroidal Anti-inflammatory Drugs Coverage Policy

Policy CodePolicy IP0457

Change TypeRemoved specific combination products

Effective DateJul 15, 2025

Next Review Date

SourceLink

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