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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsAlign Sanford Actinic Keratosis Policy | OpenPayer
    Ask Trek AI about this page
    CurrentAlign Powered by Sanford Health PlanPolicy N/A

    ACTINIC KERATOSIS - SCORE

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    This policy governs coverage of diclofenac sodium gel 3% for actinic keratosis. New therapy requires a trial of either topical fluorouracil or topical imiquimod.

    Policy Summary
    PayerAlign Powered by Sanford Health Plan
    PolicyACTINIC KERATOSIS - SCORE
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 202747d
    Next Review DateN/A
    Key ActionDocument a trial of either topical fluorouracil or topical imiquimod before requesting diclofenac sodium gel 3%.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    1Affected product
    2Topical step-therapy options
    2Products affected
    1Dapagliflozin trial required
    1Zonisamide trial required

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    New starts onlyZonisade applicability

    Coverage Criteria

    Initial Therapy Criteria

    Covered when the member has tried at least one qualifying topical therapy before diclofenac sodium gel 3%.

    Qualifying topical therapy trial

    • Topical fluorouracil: Trial of topical fluorouracil
    • Topical imiquimod: Trial of topical imiquimod

    Farxiga Step Therapy

    Covered when the member has completed the required generic trial before Farxiga.

    Farxiga prerequisite: Trial of generic dapagliflozin

    Zonisade Step Therapy

    For new starts, covered when the member has completed the required generic trial before Zonisade.

    Zonisade prerequisite: Trial of generic zonisamide capsule

    Applies to new starts only; continuation of prior therapy is approved.

    Initial Therapy

    Diclofenac Sodium Gel 3% Step Therapy

    Covered when the member has tried at least one of the following topical therapies before diclofenac sodium gel 3%.

    Required prior topical therapy

    • Topical fluorouracil: Trial of topical fluorouracil
    • Topical imiquimod: Trial of topical imiquimod

    Farxiga Initial Therapy

    Covered when the member has completed the required generic trial before Farxiga.

    Required generic trial: Trial of generic dapagliflozin

    Continuation Therapy

    Zonisade Continuation

    Covered for continuation of prior Zonisade therapy.

    Continuation of prior therapy: Approve for continuation of prior therapy.

    Documentation and Authorization Actions

    Step Therapy

    Topical Trial Required Before Diclofenac

    Before requesting coverage for diclofenac sodium gel 3%, document a trial of either topical fluorouracil or topical imiquimod. Coverage may be denied when neither qualifying topical trial has been completed.

    Step Therapy

    Generic Dapagliflozin Trial Required

    Before requesting Farxiga, document a trial of generic dapagliflozin.

    Step Therapy

    Generic Zonisamide Trial for New Starts

    For new starts of Zonisade, document a trial of generic zonisamide capsule before requesting coverage. This step requirement does not apply to continuation therapy; approve continuation of prior therapy.

    Required Step Therapy

    StepRequirement
    1Trial of either topical fluorouracil or topical imiquimod
    StepRequirement
    1Trial of generic dapagliflozin before Farxiga
    StepRequirement
    1Trial of generic zonisamide capsule before Zonisade; applies to new starts only
    Policy Summary
    PayerAlign Powered by Sanford Health Plan
    PolicyACTINIC KERATOSIS - SCORE
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJan 1, 202747d
    Next Review DateN/A
    Key ActionDocument a trial of either topical fluorouracil or topical imiquimod before requesting diclofenac sodium gel 3%.
    SourceLink
    On This Page
    Coverage CriteriaInitial TherapyContinuation TherapyDocumentation and Authorization ActionsRequired Step Therapy

    Zonisade Initial Therapy

    For new starts, covered when the member has completed the required generic trial before Zonisade.

    Required generic trial: Trial of generic zonisamide capsule

    Step applies to new starts only.