Limited coverage drugs – diclofenac IR/SR

Generic name

diclofenac immediate release

diclofenac sustained release


25 mg, 50 mg

75 mg, 100 mg



Special Authority criteria

Approval period

For the treatment of patients who have a:

  • Diagnosis of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout, or lupus


  • Treatment failure on optimal doses of, or intolerance to, ibuprofen and naproxen


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)