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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 Agents: Nonsteroidal Anti-Inflammatory Drugs (NSAIDS)

I. Prior-Authorization Requirements

 Non-Selective Nonsteroidal Anti-Inflammatory Drugs – Acetic Acid Derivatives

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

etodolac test   A90
etodolac extended-release PA   A90
indomethacin 25 mg, 50 mg test   A90
indomethacin extended-release test   A90
indomethacin suppository test  
indomethacin suspension Indocin PA  
nabumetone 1000 mg Relafen DS PA  
nabumetone 500 mg, 750 mg test   A90
sulindac test   A90
tolmetin PA   A90

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

Risk factors for NSAID-related GI toxicity:

  • Age ≥ 60 years, history of gastric or duodenal ulcer, history of gastrointestinal (GI) bleed, perforation or obstruction, concurrent use of anticoagulants, aspirin (including low doses for cardiovascular prophylaxis), corticosteroids, high daily NSAID doses.

To avoid or minimize GI toxicity:

  • Lowest effective dose should be prescribed for the shortest possible duration.
  • GI toxicity may be lower with ibuprofen, naproxen, ketoprofen, diclofenac, and higher with indomethacin, flurbiprofen, and piroxicam.

If risk factors are present for NSAID-related GI toxicity as above, consider:

  • Etodolac, nabumetone and meloxicam, all of which are preferential COX-2 inhibitors; however, with higher doses of etodolac and nabumetone, preferential inhibition of COX-2 is diminished.
  • Highly selective COX-2 inhibitor (see table below).
  • An antisecretory agent (PPI or misoprostol) with a non-selective NSAID.

Risk factors for NSAID-related renal toxicity:

  • Preexisting renal disease, severe CHF, liver disease, or diuretic use

 Ankylosing Spondylitis (AS)/Osteoarthritis(OA)/Rheumatoid Arthritis (RA) Dosing for celecoxib:

  • Celecoxib: AS: 200 mg QD or 100 mg BID, up to 400 mg/day; OA: 200 mg QD or 100 mg BID; RA: 100-200 mg BID

Sulfonamide Allergy:

  • Celecoxib is a sulfonamide derivative. The labeling for celecoxib states that use is contraindicated in sulfonamide-allergic patients.
 

 Non-Selective Nonsteroidal Anti-Inflammatory Drugs – Anthranilic Acid Derivatives

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

meclofenamate PA   A90
mefenamic acid test   A90

 Non-Selective Nonsteroidal Anti-Inflammatory Drugs – Enolic Acid Derivatives

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

meloxicam capsule Vivlodex PA   A90
meloxicam tablet Mobic test   # , A90
piroxicam Feldene test   # , A90

 Non-Selective Nonsteroidal Anti-Inflammatory Drugs – Phenylacetic Acid Derivatives

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

diclofenac / misoprostol Arthrotec PA   - < 60 years # , A90
diclofenac 1% gel test   A90
diclofenac 18 mg, 35 mg capsule Zorvolex PA   A90
diclofenac 25 mg capsule Zipsor PA   A90
diclofenac extended-release test   A90
diclofenac potassium 25 mg tablet PA   A90
diclofenac potassium 50 mg tablet test   A90
diclofenac powder for solution Cambia PA   BP
diclofenac sodium tablet test   A90
diclofenac topical patch-Flector Flector PA   A90
diclofenac topical patch-Licart Licart PA  
diclofenac topical solution Pennsaid test   BP, A90

 Non-Selective Nonsteroidal Anti-Inflammatory Drugs – Propionic Acid Derivatives

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

fenoprofen capsule Nalfon PA   A90
fenoprofen tablet PA   A90
flurbiprofen test   A90
ibuprofen test   *, A90
ibuprofen / famotidine Duexis PA   - < 60 years # , A90
ibuprofen powder PA  
ketoprofen test   A90
ketoprofen extended-release PA   A90
ketorolac nasal spray Sprix PA  
ketorolac tablets and injection PA   - > 20 units/month
naproxen / esomeprazole Vimovo PA   - <60 years # , A90
naproxen capsule, tablet test   *, A90
naproxen controlled-release Naprelan CR PA   A90
naproxen enteric coated test   A90
naproxen suspension PA   - ≥ 13 years A90
oxaprozin Daypro test   # , A90

 Non-Selective Nonsteroidal Anti-Inflammatory Drugs – Salicylic Acid Derivative

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

diflunisal test   A90
salsalate PA   A90

 Nonsteroidal Anti-Inflammatory Drugs – COX-2 (Highly Selective) NSAIDs

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes

celecoxib Celebrex test   # , A90
celecoxib oral solution Elyxyb PA  
Table Footnotes
# This designates 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.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.
 
A90 Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply.
 

II. Therapeutic Uses

FDA-approved:

  • Acute pain
  • Ankylosing spondylitis 
  • Familial adenomatous polyposis (FAP) 
  • Juvenile rheumatoid arthritis
  • Mild-to-moderate pain
  • Moderate to moderately severe pain
  • Osteoarthritis
  • Primary dysmenorrhea
  • Rheumatoid arthritis

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply depending upon diagnosis or requested medication (see below). 

 

 

Cambia

  • Documentation of the following is required:
    • diagnosis of migraine; and
    • one of the following:
      • medical records documenting an inadequate response or adverse reaction to three different NSAIDs, one of which must be diclofenac sodium; or
      • for members with a swallowing disorder or condition affecting the ability to swallow tablets, an inadequate response or adverse reaction to ibuprofen suspension and naproxen suspension.

  

diclofenac/misoprostol for members < 60 years of age

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction with concurrent therapy of diclofenac (minimum of 50 mg twice daily) and misoprostol (minimum of 200 mcg twice daily).

    

diclofenac potassium 25 capsule, diclofenac potassium 25 mg tablet, Zorvolex

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • an inadequate response or adverse reaction to an oral diclofenac product that does not require prior authorization; and 
    • an inadequate response or adverse reaction to two other different NSAIDs.

    

diclofenac topical patch (generic Flector)

  • Documentation of the following is required:
    • diagnosis of acute pain (caused by minor strains, sprains, and contusions) or osteoarthritis; and
    • an inadequate response or adverse reaction to diclofenac 1% gel.

 

Elyxyb

  • Documentation of all of the following is required:
    • appropriate diagnosis; and 
    • one of the following:
      • inadequate response or adverse reaction to celecoxib capsules; or
      • medical necessity for the use of the solution formulation as noted by one of the following:
        • requested dose is not available in the capsule formulation; or
        • member utilizes tube feeding (G-tube/J-tube); or
        • member has a swallowing disorder or condition affecting ability to swallow; or
        • member is < 13 years of age.

 

etodolac ER, ketoprofen ER, naproxen CR

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

   

fenoprofen, meclofenamate, salsalate, tolmetin

  • Documentation of the following is required:   
    • an appropriate diagnosis; and
    • an inadequate response or adverse reaction to three different oral NSAIDs.

 

ibuprofen powder

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • clinical rationale why other commercially available alternatives cannot be used.

 

ibuprofen/famotidine for members < 60 years of age

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction with concurrent therapy of ibuprofen (minimum of 800 mg three times daily) and famotidine (minimum of 20 mg three times daily).

 

Indocin suspension for all ages, and naproxen suspension for members ≥ 13 years of age

  • Documentation of the following is required:                   
    • an appropriate diagnosis; and
    • an inadequate response, adverse reaction, or contraindication to ibuprofen suspension; and
    • medical necessity for the use of the solution formulation as noted by one of the following:
      • requested dose is not available in the capsule formulation; or
      • member utilizes tube feeding (G-tube/J-tube); or
      • member has a swallowing disorder or condition affecting ability to swallow; or
      • for indocin suspension, member is <13 years of age.

 

ketorolac (tablets and injection) > 20 units/month

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • an inadequate response or adverse reaction to three different NSAIDs; and
    • clinical rationale for exceeding FDA-approved dosing/duration.  

 

ketorolac nasal spray

  • Documentation of the following is required:
    • diagnosis of moderate to moderately severe pain; and
    • one of the following:
      • medical necessity for a non-oral NSAID formulation; or
      • an inadequate response or adverse reaction to two different NSAIDs and medical records documenting an inadequate response or adverse reaction to ketorolac tablets or injection; and
    • one of the following:
      • request is within quantity limit of five bottles/30 days.

         

Licart

  • Documentation of the following is required:
    • diagnosis of acute pain (caused by minor strains, sprains, and contusions) or osteoarthritis; and
    • an inadequate response or adverse reaction to diclofenac 1% gel; and
    • an inadequate response or adverse reaction to diclofenac topical patch (generic Flector).

    

meloxicam capsule

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • an inadequate response or adverse reaction to meloxicam tablet; and
    • an inadequate response or adverse reaction to two other different NSAIDs; and
    • request is within quantity limit of one unit/day.

 

naproxen/esomeprazole for members < 60 years of age

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction with concurrent therapy of naproxen (minimum of 375 mg twice daily) and omeprazole (minimum of 20 mg twice daily).  

   

Relafen DS

  • Documentation of the following is required:
    • an appropriate diagnosis; and
    • medical records documenting an inadequate response or adverse reaction to an equivalent dose of nabumetone 500 mg or 750 mg; and
    • inadequate response or adverse reaction to two other different NSAIDs.

   

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: 09/2002

Last Revised Date: 09/2022


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Last updated 09/19/22

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