Flector — Blue Cross Blue Shield of Illinois

Preferred products

• generic topical diclofenac 1.5% solution
• generic topical diclofenac 1% gel
• brand and generic topical OTC NSAIDs

Initial criteria

• ONE of the following:
• A. Prescriber states patient has been treated with the requested agent within past 90 days and is at risk if therapy is changed OR
• B. BOTH of the following: (1) Patient diagnosed with stage four advanced, metastatic cancer or related condition and (2) Use consistent with best practices and FDA approved indication OR
• C. Patient currently treated with and stable on the requested agent OR
• D. Patient has tried and had inadequate response to generic topical diclofenac 1.5% solution or generic topical diclofenac 1% gel OR a brand or generic topical OTC NSAID [chart notes required] OR
• E. Generic topical diclofenac 1.5% solution or generic topical diclofenac 1% gel or brand/generic topical OTC NSAID discontinued due to lack of efficacy, diminished effect, or adverse event [chart notes required] OR
• F. Patient has intolerance or hypersensitivity to generic topical diclofenac 1.5% solution or generic topical diclofenac 1% gel or brand/generic topical OTC NSAID not expected to occur with requested agent [chart notes required] OR
• G. Patient has FDA labeled contraindication to generic topical diclofenac 1.5% solution AND generic topical diclofenac 1% gel AND all brand/generic topical OTC NSAIDs [chart notes required] OR
• H. Generic topical diclofenac 1.5% solution or generic topical diclofenac 1% gel or a brand/generic topical OTC NSAID expected to be ineffective or cause adherence barrier, worsen comorbidity, decrease functional ability, or cause adverse harm [chart notes required] OR
• I. Generic topical diclofenac 1.5% solution or generic topical diclofenac 1% gel or brand/generic topical OTC NSAID not in best interest of patient based on medical necessity [chart notes required] OR
• J. Patient has tried another prescription drug in same class or with same mechanism as generic topical diclofenac 1.5% solution or generic topical diclofenac 1% gel or brand/generic topical OTC NSAID and discontinued due to inefficacy or adverse event [chart notes required]
• AND patient has FDA approved diagnosis for the requested agent
• AND ONE of the following: (A) Patient not currently treated with topical lidocaine product within past 30 days OR (B) Support for appropriate concurrent use of topical lidocaine with requested agent (e.g., different indications)
• Length of Approval: 12 months

Approval duration

12 months