CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Voltaren (diclofenac sodium topical gel) prior authorization

Defines prior authorization coverage criteria and quantity limits for topical diclofenac (Voltaren Gel, RX and OTC) for treatment of osteoarthritis pain in joints amenable to topical therapy.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVoltaren (diclofenac sodium topical gel) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization (Post Limit PA) for Voltaren Gel (RX and OTC) with documentation of osteoarthritis pain in joints amenable to topical treatment and adhere to quantity limits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Topical NSAIDDrug class/agent

Osteoarthritis (topical-amenable joints)Indication

Quantity limits applySupply/limit statement

Prior Authorization Coverage Criteria

Coverage Criteria — Prior Authorization

The requested diclofenac topical gel will be covered with prior authorization when ALL of the following are met:

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ALL of the following

Patient has osteoarthritis pain in joints susceptible to topical treatment such as feet, ankles, knees, hands, wrists, or elbows
Requested drug is diclofenac sodium topical gel (Voltaren Gel, Rx or OTC)
Quantity limits are observed1000 grams / 25 days (example)
Duration of 25 days is used for a 30-day fill period and 75 days for a 90-day fill period to allow time for refill processing

What Providers Must Do

Prior Authorization

Prior authorization required

Prior authorization (Post Limit PA) is required for Voltaren Gel (RX and OTC) to be covered; approval is contingent on meeting the policy's coverage criteria and applicable quantity limits.

Documentation Required

Clinical indication documentation

Provider must document the patient's osteoarthritis pain location consistent with joints amenable to topical treatment (hands, wrists, elbows, feet, ankles, knees).

Document affected joint(s) that are topical-amenable: hands, wrists, elbows, feet, ankles, or knees.

Clinical and Administrative Background

Voltaren Gel (diclofenac sodium topical gel 1%) is indicated for relief of osteoarthritis pain in joints amenable to topical treatment, such as the knees and hands. The product has not been evaluated for use on the spine, hip, or shoulder. The over-the-counter formulation is intended for temporary relief of arthritis pain in specified upper-body areas (hand, wrist, elbow) and lower-body areas (foot, ankle, knee) and may take up to 7 days to provide relief; if no relief after 7 days, use should be discontinued. This policy references CVS Caremark criteria and is implemented as a Post Limit Prior Authorization (PA). The policy text does not list explicit ICD-10, CPT, HCPCS, or NDC codes.

Quantity limit example1000 grams / 25 days (as stated in policy)

Policy Scope and References

Defines prior authorization coverage criteria and quantity limits for topical diclofenac (Voltaren Gel, RX and OTC) for treatment of osteoarthritis pain in joints amenable to topical therapy.

Voltaren Gel (OTC) package insert: GSK Consumer Healthcare; 2021

Voltaren Gel (Rx) package insert: Endo Pharmaceuticals, Inc.; September 2018

Micromedex (IBM Watson Health)