Limited coverage drugs – diflunisal

Last updated on August 20, 2024

Generic name

diflunisal

Strength

250 mg, 500 mg

Form

tablet

Special Authority criteria

Approval period

For the treatment of patients who have a:

  • Diagnosis of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout or lupus

OR

  • Treatment failure on optimal doses of, or intolerance to, all of the following: ibuprofen, naproxen, diclofenac AND either celecoxib or meloxicam

Indefinite

Practitioner exemptions

  • Practitioners in the following specialty are not required to submit a Special Authority request form for coverage:
    • Pediatrics
    • Pediatric cardiology
    • Pediatric general surgery
    • Physical medicine and rehabilitation
    • Rheumatology

Special notes

  • Treatment failure on or intolerance to the specific medications listed in the above criteria is required. Treatment failure on or intolerance to the following NSAIDs is not sufficient: ketorolac, mefenamic acid, diclofenac potassium, naproxen sodium

Special Authority request form(s)