Limited coverage drugs – diclofenac with misoprostol

Last updated on August 20, 2024

Generic name

diclofenac with misoprostol

Strength

50 mg/200 mcg, 75 mg/200 mcg

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, all of the following: ibuprofen, naproxen, diclofenac, AND either celecoxib or meloxicam

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. Treatment failure on or intolerance to the following NSAIDs is not sufficient: ketorolac, mefenamic acid, diclofenac potassium, naproxen sodium

Special Authority request form(s)