Table 11: Nonsteroidal Anti-inflammatory Drugs

A  B   C   D   E   F   G   H I   J K   L   M   N   O   P   Q   R   S   T   U   V   W   X   Y   Z

Drug Category: Pain and inflammation
Medication Class/Individual Agent: Nonsteroidal Anti-Inflammatory Drugs (NSAIDS)

I. Prior Authorization Requirements

#   This is a brand-name drug with FDA "A"-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA "A"-rated generic equivalent.

*   The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.

II. Therapeutic Uses

• FDA-approved

III. Evaluation Criteria for Approval

• Brand name nonselective NSAIDs and mefenamic acid (see Table A)
• Ketorolac >20 units/month
• Celebrex, meloxicam, and Mobic for < 60 years old
• Brand-name Mobic
• Meloxicam suspension
• Controlled-release and extended-release NSAIDs
• Arthrotec for members < 60 years
• Flector topical patch
• Solaraze
• Voltaren Gel
• Zipsor

II. Therapeutic Uses

FDA-approved:

• acute pain
• mild-to-moderate pain
• osteoarthritis
• primary dysmenorrhea
• rheumatoid arthritis
• juvenile rheumatoid arthritis - celecoxib and meloxicam only
• familial adenomatous polyposis (FAP) - celecoxib only
• ankylosing spondylitis - celecoxib only

Note: The above list may not be all inclusive of FDA-approved indications

Back | Table 11

III. Evaluation Criteria for Approval

• All prior authorization requests must include clinical diagnosis, drug name, dose and frequency.
• Additional criteria may apply depending upon diagnosis and/or requested medication (see below).

Back | Table 11

Brand name nonselective NSAIDs and mefenamic acid (see Table A.)

• Documentation of a clinically significant adverse event to at least 2 generic, nonselective NSAIDs is required. If appropriate, at least 1 of the 2 trial drugs must include the AB-rated generic of the requested brand-name product.

Back | Table 11

Ketorolac >20 units/month

• Documentation of trials with all other less costly, safer alternatives (i.e., generic nonselective NSAIDs) is required.

Back | Table 11

Celebrex, meloxicam, and Mobic for < 60 years old

• Documentation of the following is required:
  • risk for a clinically significant gastrointestinal event or history of a gastrointestinal event; and 
  • a clinically significant adverse event or inadequate response to at least two generic nonselective NSAIDs.

SmartPA: Claims for Celebrex will usually process at the pharmacy without a prior-authorization request if the member has a history of MassHealth medical claims for an appropriate diagnosis (see therapeutic uses) and:

• a history of MassHealth pharmacy claims for at least two different generic NSAIDs, or;
• a history of pharmacy claims for warfarin, antiplatelet drug, or oral corticosteroid in the last 30 days.^†

Back | Table 11

Brand-name Mobic

• Documentation, including medical records, of a clinically significant reaction to the generic equivalent or to its inactive ingredients is required.

Back | Table 11

Meloxicam suspension

• Documentation of the following is required:
  • medical necessity for the suspension formulation; and
  • risk for a clinically significant gastrointestinal event or history of a gastrointestinal event  or a clinically significant adverse event or inadequate response to nonselective NSAIDs

Back | Table 11

Controlled-release and extended-release NSAIDs

• Documentation of the following is required:
  • appropriate diagnosis; and
  • medical necessity for an extended-release formulation over the immediate release equivalent.

Back | Table 11 

Arthrotec for members < 60 years

• Documentation of the following is required:
  • medical necessity for the combination product; and
  • risk for a clinically significant gastrointestinal event or history of a gastrointestinal event or a clinically significant adverse event or inadequate response to nonselective NSAIDs.

Back | Table 11

Flector topical patch

• Documentation of the following is required:
  • acute pain caused by minor strains, sprains, and contusions:
  • documentation of medical necessity for a transdermal formulation; and
  • a daily dose of not more than two patches/day.

Back | Table 11

Solaraze

• Documentation of the following is required:
  • Actinic Keratosis; and 
  • documentation of inadequate response to topical fluororacil and imiquimod.

Back | Table 11

Voltaren gel

• Documentation of the following is required:
  • osteoarthritis; and
  • documentation of medical necessity for a topical formulation or a clinically adverse event or inadequate response  to acetaminophen and at least two different generic nonselective NSAIDS.

Back | Table 11

Zipsor

• Documentation of the following is required:
  • mild to moderate pain; and
  • documentation of inadequate response to generic diclofenac and at least one different generic nonselective NSAID.

Back | Table 11

†  Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.

Original Effective Date: 9/2002                                                    Last Revised Date: 02/2010

Last updated 02/04/10