Solaraze (diclofenac sodium gel)
Defines prior authorization and quantity limit requirements for diclofenac sodium gel 3% (Solaraze) under the pharmacy benefit for treatment of actinic keratoses, including continuity of care for members new to the plan and initial approval duration.
Switched from SGM to Custom formulary designation at Dec P&T.
Coverage Summary
This policy: covers diclofenac sodium gel 3% (Solaraze) with criteria under the pharmacy benefit for the topical treatment of actinic keratoses. Prior authorization is required and quantity limits are enforced. The policy defines a continuity-of-care authorization pathway for members new to the plan who are currently receiving the medication (excluding products obtained as samples or via manufacturer patient assistance programs). Initial approvals are granted for 3 months. Quantity limits are set at either 100 grams per 25 days or 300 grams per 75 days as specified by the plan.