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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty Drugseternalhealth diclofenac gel coverage | OpenPayer
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    CurrenteternalHealthPolicy 26208

    ACTINIC KERATOSIS - SCORE

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    This policy governs step-therapy coverage for diclofenac sodium gel 3% used for actinic keratosis. Providers must document a trial of either topical fluorouracil or topical imiquimod before coverage.

    Policy Summary
    PayereternalHealth
    PolicyACTINIC KERATOSIS - SCORE
    Policy CodePolicy 26208
    Change TypeNo material change
    Effective DateSep 1, 2026
    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 alternatives
    1Required prior trial
    ApprovedContinuation of prior therapy

    Coverage Criteria

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    Initial Therapy Step Requirement

    Diclofenac sodium gel 3% is subject to the following step-therapy criterion.

    ONE of

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

    Initial Therapy

    For new starts,

    New-start requirement: Trial of generic zonisamide capsule is required before approval of Zonisade.

    Applies to new starts only.

    Continuation Therapy

    For patients continuing prior therapy,

    Continuation approval: Continuation of prior therapy is approved.

    Provider Actions

    Step Therapy

    Required Topical Step Therapy

    Before coverage of diclofenac sodium gel 3% for actinic keratosis, document a trial of either topical fluorouracil or topical imiquimod. Without documentation of the required topical step-therapy trial, coverage may be denied.

    • Trial of either topical fluorouracil or topical imiquimod is required before diclofenac sodium gel 3%.
    Step Therapy

    Generic Zonisamide Trial for New Starts

    For new starts of Zonisade, document a trial of generic zonisamide capsules first. The step requirement applies only to new starts; continuation of prior therapy is approved.

    • New starts: trial of generic zonisamide capsules is required before Zonisade.
    • Continuation of prior therapy: approve without requiring the generic trial.

    Initial Therapy Criteria

    Diclofenac Sodium Gel Initial Therapy

    For initial therapy with diclofenac sodium gel 3%,

    ONE of

    • Fluorouracil option: Trial of topical fluorouracil
    • Imiquimod option: Trial of topical imiquimod

    Initial Therapy

    For new starts,

    Generic zonisamide trial: Trial of generic zonisamide capsule is required.

    The step requirement applies to new starts only.

    Continuation Criteria

    Continuation Therapy

    For continuation of prior therapy,

    Prior therapy continuation: Approve continuation of prior therapy.

    Step-Therapy Requirements

    StepRequired trialBefore coverage of
    1Trial of either topical fluorouracil or topical imiquimodDiclofenac sodium gel 3%
    StepRequired trialBefore coverage ofApplies to
    1Trial of generic zonisamide capsuleZonisadeNew starts only; continuation of prior therapy is approved
    Policy Summary
    PayereternalHealth
    PolicyACTINIC KERATOSIS - SCORE
    Policy CodePolicy 26208
    Change TypeNo material change
    Effective DateSep 1, 2026
    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 CriteriaProvider ActionsInitial Therapy CriteriaContinuation CriteriaStep-Therapy Requirements