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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsGeorgia Medicaid NSAIDs Prior Auth Coverage | Open…
    Ask Trek AI about this page
    CurrentGeorgia Department of Community HealthPolicy N/A

    Georgia Medicaid Fee-for-Service NSAIDs and COX-2 Inhibitor Prior Authorization Summary

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    Rules for prior authorization, coverage criteria, and quantity/authorization limits for NSAIDs and COX-2 inhibitors under Georgia Medicaid Fee-for-Service; applies to prescribers and pharmacists submitting PA requests for covered products.

    Policy Summary
    PayerGeorgia Department of Community Health
    PolicyNSAIDs and COX-2 inhibitor prior authorization summary
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain prior authorization and document failure or intolerance to at least two preferred generic NSAIDs (or submit a written letter of medical necessity when required).
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1 yearLength of authorization
    2Required failed preferred generics
    18+Min age (diclofenac, Duexis)
    12+ / ≥38 kg

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Min age/weight (Vimovo)

    Coverage and Medical Necessity Criteria

    Non-Preferred Agent Approval

    Non-Preferred Agents (except listed exceptions) are approvable when ALL of the following are met:

    Non-Preferred general approval: Member has experienced inadequate response, allergies, contraindications, drug-drug interactions, or intolerable side effects with at least two preferred generic NSAIDs.two agents

    general step requirement

    Celecoxib Approval Criteria

    Celecoxib generic is approvable when BOTH condition-specific and trial criteria are met, except where exceptions apply:

    Eligible diagnoses for celecoxib: Member has diagnosis of familial adenomatous polyposis (FAP) OR brain cancer (brain tumor, malignant glioma) OR juvenile rheumatoid arthritis (JRA) OR acute pain OR primary dysmenorrhea OR ankylosing spondylitis (AS) OR osteoarthritis (OA) OR rheumatoid arthritis (RA).

    diagnostic eligibility

    Celecoxib trial requirement: Member has experienced ineffectiveness or intolerable side effects to at least 2 generic NSAIDs within the last 6 months.2 within 6 months

    standard requirement

    Celecoxib exceptions to trial: Celecoxib may be approved without prior use of generic NSAIDs for members currently taking an anticoagulant or on chronic oral corticosteroid therapy, or for members with a history of gastrointestinal (GI) bleed, NSAID-induced ulcer, peptic ulcer disease, or platelet dysfunction/coagulopathy.

    trial waiver conditions

    Diclofenac Potassium Powder Packets (Migraine)

    Diclofenac potassium powder packets (migraine) approval requires:

    Diclofenac potassium powder packets (migraine): Member is ≥18 years of age with a diagnosis of migraine headaches AND prescriber submits a written letter of medical necessity stating why the preferred products, generic diclofenac potassium immediate‑release and at least one other preferred generic NSAID, are not appropriate for the member.age ≥18

    written LOMN required

    Diclofenac Potassium Capsules (Acute Pain)

    Diclofenac potassium capsules (acute pain) approval requires:

    Diclofenac potassium capsules (acute pain): Member is ≥18 years of age with a diagnosis of mild to moderate acute pain AND prescriber submits a written letter of medical necessity stating why the preferred products, generic diclofenac potassium immediate‑release and at least one other preferred generic NSAID, are not appropriate for the member.age ≥18

    written LOMN required

    Duexis

    Duexis approval requires:

    Duexis (ibuprofen/famotidine): Member is ≥18 years of age with a diagnosis of rheumatoid arthritis or osteoarthritis AND prescriber submits a written letter of medical necessity stating why two separate prescriptions (generic famotidine 40 mg twice daily and generic ibuprofen or other preferred generic NSAID) are not appropriate for the member.age ≥18

    written LOMN required

    Meloxicam Capsules

    Meloxicam capsules approval requires:

    Meloxicam capsules: Member is ≥18 years of age with a diagnosis of osteoarthritis AND prescriber submits a written letter of medical necessity stating why the preferred products, generic meloxicam tablets and at least one other preferred generic NSAID, are not appropriate for the member.age ≥18

    written LOMN required

    Relafen DS

    Relafen DS approval requires:

    Relafen DS: Member is ≥18 years of age with a diagnosis of rheumatoid arthritis or osteoarthritis AND prescriber submits a written letter of medical necessity stating why the preferred product, generic nabumetone, is not appropriate for the member.age ≥18

    written LOMN required

    Vimovo

    Vimovo approval requires:

    Vimovo: Member is ≥12 years of age and weighs ≥38 kg with a diagnosis of arthritis AND prescriber submits a written letter of medical necessity stating why two separate preferred prescriptions, a preferred proton pump inhibitor (generic omeprazole or pantoprazole) and generic naproxen, are not appropriate for the member.age ≥12 and weight ≥38 kg

    written LOMN required

    Celecoxib QLL Exceptions

    Quantity Level Limit (QLL) exceptions for celecoxib:

    QLL exceedance for celecoxib: Authorization to exceed the QLL may be approvable for specified indications and dose ranges: osteoarthritis (100 mg only), rheumatoid arthritis (100 mg and 200 mg only), familial adenomatous polyposis (400 mg only), juvenile rheumatoid arthritis (50 mg and 100 mg only), ankylosing spondylitis (100 mg only), and primary dysmenorrhea (200 mg only).dose-specific

    dose/indication mapping

    Exceptions to the coverage criteria are managed through the prior authorization process. To request an exception, providers must initiate a prior authorization with OptumRx by calling 1-866-525-5827.

    Provider Requirements and Authorization Steps

    Prior Authorization

    Prior authorization required for non-preferred NSAIDs and celecoxib

    Prior authorization is required for non-preferred NSAIDs (except listed exceptions) and for celecoxib when used for the covered diagnoses. Members must have experienced inadequate response, allergies, contraindications, drug-drug interactions, or intolerable side effects with at least two preferred generic NSAIDs prior to approval, except where specific celecoxib exceptions apply.

    • Length of authorization: 1 year
    Step Therapy

    Step therapy: two preferred generics required before non-preferred approval

    Require trial and failure of at least two preferred generic NSAIDs (ineffectiveness or intolerable side effects within the last 6 months) before non-preferred agents will be approved. Celecoxib may be approved without this two-drug trial for members currently taking an anticoagulant, on chronic oral corticosteroid therapy, or with a history of GI bleed/NSAID-induced ulcer/peptic ulcer disease or platelet dysfunction/coagulopathy.

    • Trial window: within the last 6 months

    Step Therapy Requirements

    RequirementDetails
    Step therapy requirementMember has experienced inadequate response, allergy, contraindication, drug–drug interaction, or intolerable side effects with at least two preferred generic NSAIDs (trial and failure of 2 preferred generics).
    Timeframe for prior trialsIneffectiveness or intolerable side effects to at least 2 generic NSAIDs within the last 6 months.
    Celecoxib exceptions (trial waiver)Celecoxib generic may be approved without prior use of generic NSAIDs for members currently taking an anticoagulant, on chronic oral corticosteroid therapy, or with a history of gastrointestinal bleed, NSAID‑induced ulcer, peptic ulcer disease, or platelet dysfunction/coagulopathy.

    Drug Indications and Definitions

    Celecoxib approvable indications
    Familial adenomatous polyposis (FAP)Celecoxib generic is approvable for members with a diagnosis of familial adenomatous polyposis.
    Brain cancer (malignant glioma)Celecoxib generic is approvable for members with a diagnosis of brain cancer (brain tumor, malignant glioma).
    Juvenile rheumatoid arthritis (JRA)Celecoxib generic is approvable for members with a diagnosis of juvenile rheumatoid arthritis.
    Acute painCelecoxib generic is approvable for members with a diagnosis of acute pain.
    Primary dysmenorrheaCelecoxib generic is approvable for members with a diagnosis of primary dysmenorrhea.
    Ankylosing spondylitis (AS)Celecoxib generic is approvable for members with a diagnosis of ankylosing spondylitis.

    Background and Clinical Context

    Nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 inhibitors (COX-2 inhibitors) are commonly used to treat pain and inflammation and to manage chronic conditions such as osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, juvenile rheumatoid arthritis, and certain specialized indications (for example, familial adenomatous polyposis and some cancer-related uses). Safety considerations—particularly gastrointestinal bleeding or ulcer risk and disorders of platelet function or coagulation—influence coverage and may create exceptions to step-therapy requirements for COX-2 inhibitors (for example, celecoxib) in certain patients.

    Policy Summary
    PayerGeorgia Department of Community Health
    PolicyNSAIDs and COX-2 inhibitor prior authorization summary
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain prior authorization and document failure or intolerance to at least two preferred generic NSAIDs (or submit a written letter of medical necessity when required).
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaProvider Requirements and Authorization StepsStep Therapy RequirementsDrug Indications and DefinitionsBackground and Clinical Context
  1. Required failures: at least 2 preferred generic NSAIDs
    2. Documentation Required

    Written letter of medical necessity required for specified products

    For diclofenac potassium powder packets, diclofenac potassium capsules, Duexis, meloxicam capsules, Relafen DS, and Vimovo, the prescriber must submit a written letter of medical necessity explaining why the specified preferred products are not appropriate for the member.

    • Diclofenac potassium powder packets and capsules: explain why generic diclofenac potassium IR and at least one other preferred generic NSAID are not appropriate (member ≥18).
    • Duexis: explain why two separate prescriptions (generic famotidine 40 mg BID and generic ibuprofen or other preferred NSAID) are not appropriate (member ≥18 with RA or OA).
    • Meloxicam capsules: explain why preferred meloxicam tablets and at least one other preferred generic NSAID are not appropriate (member ≥18 with OA).
    • Relafen DS: explain why preferred generic nabumetone is not appropriate (member ≥18 with RA or OA).
    • Vimovo: explain why two separate preferred prescriptions (preferred PPI and generic naproxen) are not appropriate (member ≥12 and ≥38 kg with arthritis).
    Denial Risk

    Denial risk if step therapy or contraindications are not documented

    Requests for non-preferred agents will be denied unless the member has documented inadequate response, allergy, contraindication, drug-drug interaction, or intolerable side effects to at least two preferred generic NSAIDs; lack of documentation of required step therapy or absence of documented contraindication/ intolerance will trigger denial.

    • Denial trigger: failure to document trial/failure of at least two preferred generic NSAIDs or to document an approved exception (e.g., anticoagulant use, chronic steroid therapy, history of GI bleed/ulcer, platelet dysfunction/coagulopathy).
    Osteoarthritis (OA) or Rheumatoid arthritis (RA)Celecoxib generic is approvable for members with a diagnosis of osteoarthritis or rheumatoid arthritis.