Limited Use Note(s)

CELECOXIB200mg Cap
Reason For Use CodeClinical Criteria
Osteoarthritis
316For patients who have failed an adequate trial of acetaminophen (e.g. acetaminophen 1g QID for several weeks) and have had:
History of a documented, clinically significant ulcer or GI bleed; or Failure or intolerance to at least three listed NSAIDS.
NOTE: The maximum daily dose of celecoxib which will be reimbursed for the treatment of osteoarthritis is 200mg.
LU Authorization Period: 1 year
Rheumatoid arthritis
317For patients who have had:
History of a documented, clinically significant ulcer or GI bleed; or Failure or intolerance to at least three listed NSAIDS.
NOTE: The maximum daily dose of celecoxib which will be reimbursed for the treatment of rheumatoid arthritis is 400mg.
LU Authorization Period: 1 year