diclofenac potassium 25 mg tablet — Highmark

Preferred products

• oral generic NSAIDs (one must be oral diclofenac)

Initial criteria

• age ≥ 18 years
• diagnosis of primary dysmenorrhea (ICD-10: N94.4) OR mild to moderate pain (ICD-10: R52) OR osteoarthritis (ICD-10: M15, M16, M17, M18, M19) OR rheumatoid arthritis (ICD-10: M05, M06)
• therapeutic failure, contraindication, or intolerance to three plan-preferred formulary, oral generic NSAIDs, one of which must be oral diclofenac (e.g., diclofenac sodium oral tablet, delayed release or extended release)

Reauthorization criteria

• member continues to use the medication for an FDA approved indication
• prescriber attests that the member has experienced positive clinical response to therapy

Approval duration

12 months