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)