Celecoxib (Celebrex)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Osteoarthritis (OA)
  • Rheumatoid Arthritis (RA)
  • Juvenile Rheumatoid Arthritis (JRA)
  • Anklosing Spondylitis (AS)
  • Acute Pain (AP)
  • Primary Dysmenorrhea (PD)

Patients must meet the following criteria for the indications listed above:

  • Patient is < 65 years old, AND
  • Has tried and failed at least two different oral, select, prescription-strength, non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment condition OR is taking a select anticoagulant within the last 130 days evidenced by claims or as documented in medical record documentation

Dosing:

  • Osteoarthritis: 200 mg once daily or 100 mg twice daily
  • Rheumatoid Arthritis: 100 to 200 mg twice daily
  • Juvenile Rheumatoid Arthritis:
    • 10-25 kg: 50 mg twice daily
    • > 25 kg: 100 mg twice daily
  • Anklosing Spondylitis: 200 mg once daily or 100 mg twice daily.  If no effect after 6 weeks, 400 mg may be of benefit
  • Acute Pain and Primary Dysmenorrhea: Initial: 400 mg, followed by 200 mg if needed on first day.  On subsequent days, 200 mg twice daily as needed

Approval:

  • Chronic conditions: one year