Limited coverage criteria – diclofenac with misoprostol

 

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Generic name	diclofenac with misoprostol
Strength & form	50 mg/200 mcg, 75 mg/200 mcg 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

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• HLTH 5328 - General Special Authority Request (PDF, 656KB)