Nonsteroidal Anti-Inflammatory Drugs - Diclofenac

Generic Name                             

diclofenac with or without misoprostol                                                                                                                                                                                                                                                                                                                                                                       

Strength

25 mg, 50 mg;
50 mg/200 mcg, 75 mg/200 mcg
Form

tablet

Special Authority Criteria

Approval Period
1. Diagnosis of rheumatoid or psoriatic arthritis, ankylosing spondylitis, gout or lupus.

OR

2. Treatment failure on optimal dose of, or intolerance to, at least one of the following: ASA-enteric coated, ibuprofen, or 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

  • Full coverage for diclofenac 75 mg and 100 mg sustained release products is provided only for individuals who have documented breakthrough symptoms while on the regular release form for a trial period at usual adult doses for at least 4 weeks. Full coverage cannot be provided for dosage convenience.
  • Topical diclofenac is not eligible for PharmaCare coverage.
  • Suppositories are regular benefits and not subject to the RDP.

Special Authority Request Form(s)