Rational Drug Therapy Program WVBMS Drug Therapy Guidelines  Nonsteroidal Anti-Inflammatory  Drug (NSAID) Criteria   NSAID Form

All brand name non-steroidal anti-inflammatory medications and COX-2 inhibitors require prior approval.

COX-2 inhibitors or NSAID products containing a combination of an NSAID and misoprostol will be approved by utilizing the NSAID Risk scale.

The following is the policy for the approval of payment of COX-2 inhibitors or misoprostol/NSAID combinations:

1. Any patient using a full dose prescription NSAID and greater than 70 years of age.
2. Any patient using a full dose prescription NSAID with a history of serious NSAID gastrointestinal     complications (e.g. GI Bleed requiring hospitalization).
3. Any patient using a full dose prescription NSAID and NOT falling into the above two (2) categories must have a total point score of thirteen (13) points or more from the chart below:

Patients Age / Issue Points  Patient’s Points	Points	Patient’s Points
<25	0
26-30	1
31-35	2
36-40	3
41-45	4
46-50	5
51-55	6
56-60	7
61-65	8
66-70	9
71-75	10
Concurrent Oral Steroid	Use No = 0    Yes = 4
History of NSAID GI Side Effects	None = 0 Occasional = 4 Frequent = 5
Current NSAID	Use OTC or PRN Rx = 0   RX = 1
General Health Status (Select only one limitation category)	No function limitation = 0 Patient limited in recreational activities = 1 Patient limited in vocational activities = 2 Patient limited in self-care activities = 3
	SUM OF POINTS

Rational Drug Therapy Program West Virginia University School of Pharmacy P.O. Box 9511 Morgantown, WV 26506-9511 Phone 800 847 3859 Fax 800 531 7787