Limited coverage criteria – diclofenac IR/SR

 

Return to Special Authority drug list 

Generic name	diclofenac immediate release diclofenac sustained release
Strength & form	25 mg, 50 mg tablet 75 mg, 100 mg 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)

• Log in to eForms
• HLTH 5328 - General Special Authority Request (PDF, 656KB)