North Carolina Prior Authorization Program

Therapeutic Class Code: S2B
Therapeutic Class Description: Non-Steroidal Anti-inflammatory Drugs including COX-2 inhibitors

Medication Generic Code Number(s)
Celebrex (Celecoxib) 18127, 42001, 42002, 97785

Early Periodic Screening, Diagnostic and Treatment Provision

Early Periodic Screening, Diagnostic and Treatment (EPSDT) allows a recipient less than 21 years of age to receive services in excess of the limitations or restrictions below and without meeting the specific criteria in this section when such services are medically necessary health care services to correct or ameliorate a defect, physical or mental illness, or a condition [health problem]; that is, documentation shows how the service product or procedure will correct or improve or maintain the recipient’s health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems.

EPSDT DOES NOT ELIMINATE THE REQUIREMENT FOR PRIOR APPROVAL IF PRIOR APPROVAL IS REQUIRED.  Additional information on EPSDT guidelines may be access at http://www.ncdhhs.gov/dma/epsdt/

Criteria:

1. Management of acute and chronic pain in adults if at least one of the following indications are met:

a. history of GI bleed or gastric or duodenal ulcer
b. previous intolerance to at least two non-COX-2 classes of NSAIDs at therapeutic doses
c. concurrent use of corticosteroids
d. concurrent use of warfarin or heparin
e. history of platelet dysfunction or coagulopathy

2. Use in reducing the number of adenomatous colorectal polyps in familial adenomatous polyposis (FAP).

3. Patients 60 years of age and older do not require prior authorization.

May be approved for up to 6 months

References:

1. Pfizer Inc. Celebrex package insert. New York (NY): 2001 Oct.

2. Drug class review on cyclo-oxygenase (COX)-2 inhibitors and non-steroidal anti-inflammatory drugs (NSAIDs) Final Report. Update 3. Nov 2006. Evidence Based Practice Centers. Oregon Health Sciences University.

3. Bertagnolli MM. Celecoxib for the prevention of sporadic colorectal adenomas. N Engl J Med. 2006 Aug 31; 355(9):873-84.

4. White, W.B, West, C.R, et al. Risk of Cardiovascular Events in Patients Receiving Celecoxib: A Meta-Analysis of Randomized Clinical Trials. Am J Cardiol 2007; 99:91-98.