Diclofenac sodium gel 3% (Solaraze) — Prior Authorization and Quantity Limits
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Defines prior authorization, quantity limits, and coverage criteria for diclofenac sodium gel 3% under the pharmacy benefit for Mass General Brigham Health Plan commercial/exchange members.
Updated language for members who are new to the Plan regarding documentation requirements and set effective date 07/01/2026.
Coverage Criteria
Coverage Criteria
Authorization may be granted when clinical and documentation criteria are met.
ALL of the following
ALL of the following
- Requested medication is being prescribed for the treatment of actinic keratoses (AK).
Reference: indication requirement
ALL of the following
- If member is new to the plan: When coverage effective date is less than or equal to 90 days: submit medical records documenting that the member is currently receiving treatment with the requested drug (documentation must exclude samples and manufacturer patient assistance).
New-to-plan documentation requirement
- If member is established or not new to plan: Standard prior authorization documentation demonstrating appropriateness of therapy per plan requirements (medical records supporting diagnosis and prescription).
Standard PA documentation
ALL of the following
- Approvals will be granted for 3 months.
Approval duration
- Quantity limit options: One of the following quantity limits applies: 100 grams per 25 days OR 300 grams per 75 days.
Enforced quantity limits
ALL of the following
- Documentation must not include medication obtained only as samples or via manufacturer's patient assistance programs when used to meet the new-to-plan requirement.
Exclusions for acceptable documentation
Coding and Quantity Rules
| No codes listed |
Provider Actions and Authorization Requirements
Prior authorization and documentation required for AK; additional records for new-to-plan members
Prior authorization is required under the pharmacy benefit for diclofenac sodium gel 3% when prescribed for actinic keratoses. For members new to the Plan (coverage effective date ≤ 90 days), submit medical records showing the member is currently receiving treatment with the requested drug; documentation should exclude samples or manufacturer patient assistance program supplies.
- Program Type: Prior Authorization and Benefit: Pharmacy Benefit must be applied when requesting coverage.
- For members new to plan (coverage effective date ≤ 90 days): include medical records documenting current use of the requested drug (do not submit records showing only samples or manufacturer patient assistance).
Quantity limits enforced; approvals issued for 3 months
Quantity limits are enforced for diclofenac sodium gel 3%; approvals will be granted for a 3-month duration.
- Quantity limits: 100 grams per 25 days
- Alternate quantity limit: 300 grams per 75 days
- Approval duration for granted authorizations: 3 months
Definitions
Continuation / New-to-Plan Therapy
Continuation / New-to-Plan Therapy
Documentation expectations for members new to the plan and review history.
ALL of the following
ALL of the following
- Medical records demonstrating the member is currently receiving treatment with the requested drug.
Exclude documentation of samples or manufacturer patient assistance programs
ALL of the following
- Policy language updated April 15, 2026; effective date 07/01/2026.
Administrative history
Documented Quantity Limits
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