Diclofenac sodium 3% topical gel — Highmark

Preferred products

• fluorouracil solution
• fluorouracil 5% cream
• imiquimod 5% topical cream

Initial criteria

• age ≥ 18 years
• diagnosis of actinic keratosis (ICD-10: L57.0)
• therapeutic failure or intolerance to one of the following, or contraindication to all: fluorouracil solution OR fluorouracil 5% cream
• therapeutic failure or intolerance to plan-preferred generic imiquimod 5% topical cream

Reauthorization criteria

• prescriber attests that the member previously responded to diclofenac sodium 3% topical gel therapy
• prescriber attests the member is re-starting therapy at least 30 days after cessation of diclofenac sodium 3% topical gel therapy

Approval duration

3 months