Limited Coverage Drugs - diclofenac IR/SR
Generic Name |
|
---|---|
Strength |
|
Form |
tablet |
Special Authority Criteria |
Approval Period |
---|---|
For the treatment of patients who have a:
OR
|
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)