Prior Auth Protocol

FDA Approved Indications:

Health Net Approved Indications and Usage Guidelines:

Failure or clinically significant adverse effect to indomethacin and one other preferred non-steroidal anti-inflammatory drug (NSAID) at prescription doses

Coverage is Not Authorized For:

Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.

General Information:

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Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
indomethacin (Indocin^R)	25 - 50 mg PO BID-TID	20 mg/day
indomethacin SR (Indocin^R SR)	75 mg PO QD - BID	150 mg/day
diclofenac sodium (Voltaren^R)	50 mg PO TID	150 mg/day
etodolac (Lodine^R)	400 - 500 mg PO BID	1200 mg/day
fenoprofen (Nalfon^R)	200 mg PO Q4-6hr	3200 mg/day
flurbiprofen (Ansaid^R)	100 mg PO BID-TID	300 mg/day
ibuprofen (Motrin^R)	400 - 800 mg PO Q6-8hr	3200 mg/day
ketoprofen (Orudis^R, Oruvail^R)	25-75 mg PO Q6-8hr	300 mg/day
ketorolac tromethamine	10 mg PO q4-6hr	40 mg/day
meclofenamate (Meclomen^R)	50 - 100 mg PO Q4-6hr	400 mg/day
meloxicam (Mobic^R)	7.5 mg -15 mg PO QD	15 mg/day
nabumetone (Relafen^R)	1000 mg PO QD	2000 mg/day
naproxen(Naprosyn^R)	250 - 500 mg PO BID	1500 mg/day
naproxen ER (Naprelan^R)	750 - 1000 mg PO QD	1500 mg/day
naproxen sodium (Anaprox^R, Anaprox DS^R)	275 - 550 mg PO BID	1650 mg/day
oxaprozin (Daypro^TM)	600 - 1,200 mg PO QD	1800 mg/day
piroxicam (Feldene^R)	10 - 20 mg PO QD	20 mg/day
salsalate(Disalcid^R)	500 - 750 mg PO BID- TID, titrated up to 3000 mg/day	3000 mg/day
sulindac (Clinoril^R)	150 mg - 200 mg PO BID	400 mg/day
tolmetin (Tolectin^R)	400 mg PO TID, titrated up to 1800 mg/day	1800 mg/day

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Tivorbex	20 mg PO TID or 40 mg PO BID - TID	Length of Benefit

Product Availability:

Capsules: 20mg, 40 mg

References:

1. Tivorbex [prescribing information]. Iroko Pharmaceuticals, Philadelphia, PA; February 2014.

2. Micromedex^RHealthcare Series [Internet database]. Greenwood Village, Colo: Thompson Healthcare. Updated periodically. Accessed September 2015.