Zipsor (diclofenac potassium capsule) — Highmark
mild to moderate pain
Preferred products
- oral generic NSAIDs (one must be oral diclofenac)
Initial criteria
- age ≥ 12 years
- diagnosis of mild to moderate pain (ICD-10: R52)
- therapeutic failure, contraindication, or intolerance to three plan-preferred formulary, oral generic NSAIDs, one of which must be oral diclofenac
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