Zorvolex (diclofenac capsule) — Highmark
mild to moderate acute pain
Preferred products
- oral generic NSAIDs (one must be oral diclofenac)
Initial criteria
- age ≥ 18 years
- diagnosis of mild to moderate acute pain (ICD-10: R52) OR osteoarthritis (ICD-10: M15, M16, M17, M18, M19)
- 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