Lofena (diclofenac potassium 25 mg tablet) — Highmark
primary dysmenorrhea
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