Licart — Blue Cross Blue Shield of Montana

Preferred products

• diclofenac topical solution 1.5%
• diclofenac topical gel 1%
• topical OTC NSAIDs

Initial criteria

• ONE of the following:
• A. The prescriber states the patient has been treated with the requested agent within the past 90 days AND is at risk if therapy is changed OR
• B. BOTH of the following:
• 1. ONE of the following:
• A. The prescriber has stated or documented that the patient has stage four advanced, metastatic cancer and the requested agent is being used to treat the cancer or an associated condition AND
• 2. The use of the requested agent is consistent with best practices, supported by peer-reviewed literature, and FDA approved OR
• C. The patient is currently being treated with and stable on the requested agent [chart notes required] OR
• D. The patient has tried and had an inadequate response to generic topical diclofenac 1.5% solution OR generic topical diclofenac 1% gel OR a brand/generic topical OTC NSAID [chart notes required] OR
• E. The above agents were discontinued due to lack of efficacy/effectiveness/adverse event [chart notes required] OR
• F. The patient has an intolerance or hypersensitivity to generic topical diclofenac 1.5% solution OR generic topical diclofenac 1% gel OR topical OTC NSAID not expected with requested agent [chart notes required] OR
• G. The patient has an FDA labeled contraindication to generic topical diclofenac 1.5% solution AND generic topical diclofenac 1% gel AND all topical OTC NSAIDs that is not expected with the requested agent [chart notes required] OR
• H. The alternative agents are expected to be ineffective or cause adverse outcomes based on patient’s characteristics, adherence issues, or comorbid conditions [chart notes required] OR
• I. The alternatives are not in the best interest of the patient based on medical necessity [chart notes required] OR
• J. The patient has tried another prescription drug in the same pharmacologic class or mechanism of action and discontinued due to lack of efficacy/effectiveness/adverse event [chart notes required]
• AND the patient has an FDA approved diagnosis for the requested agent
• AND ONE of the following regarding lidocaine use:
• A. The patient is not currently treated with a topical lidocaine product within the past 30 days OR
• B. There is support for appropriate concurrent use of topical lidocaine with the requested agent for different indications.

Approval duration

12 months