CurrentmhnPolicy CP.CPA.296

Meloxicam Capsule

Defines medical necessity criteria, dosing limits, and prior authorization requirements for meloxicam 5 mg and 10 mg capsules for commercial lines of business; applies to providers submitting requests for coverage under the plan.

Policy Summary

Payermhn

PolicyMeloxicam Capsule

Policy CodePolicy CP.CPA.296

Change TypeRevision (non‑material noted)

Effective Date11.16.16

Next Review Date

Key ActionSubmit prior authorization with documentation showing diagnosis, age ≥18, failure of required therapies, and dose ≤10 mg/day.

SourceLink

POLICY UPDATE CHANGES

Removed brand Vivlodex from policy due to product discontinuation; clarified that this policy is applicable to meloxicam 5 mg and 10 mg capsules.

Clarified failure of generic meloxicam 'tablet' and added 'must use generic formulation' language for brand Vivlodex (prior revision).

Revised approval duration for Commercial line of business to 12 months or duration of request, whichever is less.

5 mg, 10 mgcapsule strengths covered

10 mg/daymaximum dose allowed

12 monthsapproval duration

≥18age requirement

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Coverage Criteria

Initial Approval — Osteoarthritis or Rheumatoid Arthritis Pain (off-label)

Covered when ALL of the following are met:

Initial approval criteria: 1. Diagnosis of osteoarthritis (OA) or rheumatoid arthritis; 2. Age ≥ 18 years; 3. Request is for meloxicam 5 mg or 10 mg capsules; 4. Failure of both of the following at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated: (a) generic meloxicam tablet; (b) one other preferred NSAID (See Appendix B); 5. Dose does not exceed 10 mg per day.10 mg/day

Approval duration: 12 months or duration of request, whichever is less

Continued Therapy — Osteoarthritis or Rheumatoid Arthritis Pain (off-label)

Continued coverage when ALL of the following are met:

Continued therapy criteria: 1. Member meets one of the following: (a) currently receiving medication via Centene benefit or previously met initial approval criteria; (b) currently receiving medication and enrolled in a state/product with continuity of care regulations; 2. Member is responding positively to therapy; 3. If request is for a dose increase, new dose does not exceed 10 mg per day.10 mg/day

Approval duration: 12 months or duration of request, whichever is less

Other diagnoses/indications

If request is for other diagnoses/indications:

Other uses path: 1. If the drug has had a label change within the last 6 months not yet reflected in this policy, refer to CP.CPA.190 (no coverage/non‑formulary) as applicable to formulary status; 2. If the requested use (diagnosis, age, dosing) is not specifically listed under section III and criterion 1 does not apply, refer to the off‑label use policy CP.CPA.09 for commercial lines of business.

Requests for meloxicam for non‑FDA approved indications that are not specifically addressed in this policy will not be authorized unless the provider supplies sufficient documentation of efficacy and safety in accordance with the Health Plan's off‑label use policy (CP.CPA.09) or the member's evidence of coverage documents. Authorization for off‑label uses will be considered only when the submitted clinical information meets the standards described in CP.CPA.09 or when the applicable coverage documents permit such use.

Coverage determinations under this clinical policy are subject to the terms, conditions, exclusions, and limitations of the member's coverage documents (for example, evidence of coverage, certificate of coverage, policy or contract of insurance), as well as applicable state and federal requirements and Health Plan administrative policies. This policy is intended to guide medical necessity decisions and does not constitute a contract or guarantee of payment; providers must follow contract terms and applicable administrative procedures when submitting requests for meloxicam capsules.

Coding and Dose Limits

Maximum daily dose

Maximum daily dose10 mg/day

Dosing regimen5-10 mg PO QD

Capsule strengths covered5 mg, 10 mg

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for meloxicam 5 mg and 10 mg capsules. Meloxicam capsules are considered medically necessary only when the criteria in the policy's Initial Approval Criteria are met.

Applies specifically to meloxicam 5 mg and 10 mg capsules.
Approval duration for initial therapy: up to 12 months or duration of request, whichever is less.

Step Therapy

Step Therapy / Preferred Alternatives

Step therapy must be followed before meloxicam capsules will be approved. The member must have failed both: (a) generic meloxicam tablet, and (b) one other preferred NSAID (see Appendix B) at up to maximally indicated doses, unless contraindicated or clinically significant adverse effects occur.

Failure of generic meloxicam tablet is required.
Failure of one other preferred NSAID from Appendix B is required.

Background

Meloxicam is a non‑steroidal anti‑inflammatory drug (NSAID) commonly used for management of osteoarthritis pain and, per this policy, may be used for rheumatoid arthritis pain when the specified criteria are met. As an NSAID, meloxicam has class-associated cardiovascular and gastrointestinal boxed warnings and contraindications; prescribers should consider these risks and follow the Appendix C safety information and standard clinical monitoring when initiating or continuing therapy.

Definitions

NSAID

DefinitionNon-steroidal anti-inflammatory drug (NSAID)

Example agent in this policyMeloxicam (an NSAID)

Class-specific boxed warningsCardiovascular thrombotic events; gastrointestinal bleeding, ulceration, and perforation

Health Plan

DefinitionHealth Plan — a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or affiliates.

Policy applicability noteThis clinical policy is effective as of the date determined by the Health Plan; posting date may differ and the plan may change, amend, or withdraw the policy.

Revision History

2025-07-14annual reviewLatest

4Q 2025 annual review: no significant changes; references reviewed and updated.

2024-07-15annual review

4Q 2024 annual review: removed brand Vivlodex due to product discontinuation and clarified policy applies to meloxicam 5 mg and 10 mg capsules; references reviewed and updated.

2022-07-28annual review

Policy Summary

Payermhn

PolicyMeloxicam Capsule

Policy CodePolicy CP.CPA.296

Change TypeRevision (non‑material noted)

Effective Date11.16.16

Next Review Date

Key ActionSubmit prior authorization with documentation showing diagnosis, age ≥18, failure of required therapies, and dose ≤10 mg/day.

SourceLink

On This Page

Documentation Required

Required Supporting Documentation

Providers must submit supporting documentation (e.g., office chart notes, lab results, other clinical information) demonstrating that the member meets all approval criteria. Incomplete or insufficient documentation may result in denial of the request.

Include documentation of diagnosis, prior therapies tried (including dosing and dates), reasons for discontinuation or intolerance, and current dosing request.
Requests for non‑FDA approved indications require sufficient documentation of efficacy and safety per the off‑label use policy CP.CPA.09.

Denial Risk

Denial Risk for Insufficient Documentation or Unauthorized Indications

Denial Risk: Requests that do not meet the policy criteria (including required step therapy failures, age criteria, indication, or documentation) or that exceed the maximum daily dose specified in the policy may be denied.

Dose limit: meloxicam capsules should not exceed 10 mg per day as specified in the Initial Approval Criteria.
Non‑covered indications as listed in the policy (e.g., non‑FDA approved uses not supported by adequate documentation) are excluded from authorization.

Note

Provider Responsibility and Policy Applicability

Provider Responsibility and Policy Applicability: Providers are expected to exercise professional medical judgment; this clinical policy is a guide to medical necessity and does not guarantee payment. The policy is effective as of the Health Plan–determined date and the plan may change, amend, or withdraw the policy at any time. Coverage decisions remain subject to the terms, conditions, exclusions, and limitations of the member's benefit documents.

The date of posting may not be the effective date; legal/regulatory requirements govern where discrepancies exist.
This policy does not dictate clinical care — providers retain responsibility for treatment decisions.

Coverage administration reminder

Coverage decisions and administration of benefits are subject to all terms, conditions, exclusions, and limitations of the member's coverage documents and applicable legal/regulatory requirements.

4Q 2022 annual review: clarified failure of generic meloxicam 'tablet', added 'must use generic formulation' language for brand Vivlodex; template changes applied to other diagnoses/indications and continued therapy section; references reviewed and updated.

2021-09-27policy change

Revised approval duration for Commercial line of business to 12 months or duration of request, whichever is less.

2021-06-25annual review

4Q 2021 annual review: no significant changes; references reviewed and updated.