Vivlodex (meloxicam) — Highmark
osteoarthritis
Preferred products
- generic meloxicam tablets
- other plan-preferred, generic, formulary NSAIDs
Initial criteria
- Diagnosis of osteoarthritis (ICD-10: M15, M16, M17, M18, M19)
- Therapeutic failure or intolerance to plan-preferred, generic meloxicam tablets
- Therapeutic failure, contraindication, or intolerance to two (2) additional plan-preferred, generic, formulary NSAIDs
Reauthorization criteria
- Prescriber attests that the member has experienced positive clinical response to therapy
Approval duration
12 months