Limited coverage drugs – diclofenac IR/SR

Generic name

diclofenac immediate release

diclofenac sustained release

Strength

25 mg, 50 mg

75 mg, 100 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, ibuprofen and naproxen

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

  • Topical diclofenac is not eligible for PharmaCare coverage. Compounded preparations should be processed under PIN 66128220 NSAID topical compound (non-benefit)
  • Diclofenac suppositories are regular benefits
  • Treatment failure on or intolerance to the specific medications listed in the above criteria is required

Special Authority request form(s)