CurrentNeighborhood Health Plan of Rhode IslandPolicy 1729-J 07-2022

Voltaren Gel (diclofenac sodium topical gel 1%) prior authorization

Defines prior authorization requirements for Voltaren Gel (diclofenac sodium topical gel 1%) for treatment of osteoarthritis pain in joints amenable to topical therapy; applies to members subject to Neighborhood Health Plan of Rhode Island pharmacy benefit following CVS Caremark criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVoltaren Gel (diclofenac sodium topical gel 1%) prior authorization

Policy CodePolicy 1729-J 07-2022

Change TypeNo material change

Effective DateJul 1, 2022

Next Review Date

Key ActionObtain prior authorization and document osteoarthritis pain in joints amenable to topical treatment; ensure requested quantity conforms to the 1000 grams per 25 days limit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1%active ingredient concentration

1000 g/25dquantity limit

7 daysOTC trial

Coverage Criteria

Coverage criteria

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ALL of the following

Indication: Patient has osteoarthritis pain in joints susceptible to topical treatment such as feet, ankles, knees, hands, wrists, or elbows
Quantity limits: Requested quantity conforms to Quantity Limits (1000 grams per 25 days for a 30-day fill; 75 days used for a 90-day fill period processing allowance)1000 grams/25 days

ALL of the following

Drug formulation: Voltaren Gel (diclofenac sodium topical gel 1%) is used; OTC product is for temporary relief and may take up to 7 days to work
OTC instruction: stop use if no relief in 7 days

Coding and Drug

Covered drugNDC|genericCovered

diclofenac sodium topical gel 1%

Voltaren Gel (brand and OTC)

Quantity limit

Quantity limit (expressed)1000 grams per 25 days (30-day fill period)

Processing allowance25 days used to represent a 30-day fill; 75 days used for a 90-day fill to allow refill processing

Unitgrams

Voltaren Gel (diclofenac sodium topical gel 1%)

DrugVoltaren Gel (diclofenac sodium topical gel 1%)

IndicationRelief of osteoarthritis pain in joints amenable to topical treatment (e.g., knees, hands)

Quantity limit applied1000 grams per 25 days

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required — Voltaren Gel (diclofenac sodium topical gel 1%) is subject to Post Limit Prior Authorization through CVS Caremark. Requests must meet the coverage criteria below for approval.

Product: Voltaren Gel (diclofenac sodium topical gel 1%)
Authorization type: Post Limit Prior Authorization
Program: CVS Caremark

Documentation Required

Provider must document the patient has osteoarthritis pain in joints amenable to topical treatment (for example: feet, ankles, knees, hands, wrists, or elbows). Also note quantity limits apply.

Required clinical documentation: diagnosis of osteoarthritis and location of joint(s) treated
Quantity limit: 1000 grams per 25 days (30-day fill basis); 75 days used for 90-day fill processing

Denial Risk

Denial Risk for Unsupported Indication

Requests that do not meet the coverage criteria (for example, for indications other than osteoarthritis pain in joints amenable to topical treatment) may be denied.

Common denial reason: indication not for osteoarthritis pain in eligible joints
Ensure submitted documentation clearly supports the covered indication and dosing/quantity requested

Initial Therapy Criteria

OTC initial trial guidance

Recommended initial OTC trial guidance before requesting prior authorization:

ALL of the following

Duration to assess effect: OTC Voltaren Arthritis Pain may take up to 7 days to work for arthritis pain; if no relief in 7 days, stop use7 days
Temporary relief only

ALL of the following

Applicable sites: OTC product is intended only for joints amenable to topical treatment (hand, wrist, elbow, foot, ankle, knee) and is not evaluated for spine, hip, or shoulder
If pain is in spine, hip, or shoulder, OTC use is outside indicated uses and may not be appropriate

Site of Care

Note

Site of care limitation — home topical use only for amenable joints

Topical application is limited to joints amenable to topical treatment; use on the spine, hip, or shoulder is not evaluated in the product labeling.

Joints amenable to topical treatment include hands, wrists, elbows, feet, ankles, and knees.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVoltaren Gel (diclofenac sodium topical gel 1%) prior authorization

Policy CodePolicy 1729-J 07-2022

Change TypeNo material change

Effective DateJul 1, 2022

Next Review Date

Key ActionObtain prior authorization and document osteoarthritis pain in joints amenable to topical treatment; ensure requested quantity conforms to the 1000 grams per 25 days limit.

SourceLink

On This Page

OpenPayer

Voltaren Gel (diclofenac sodium topical gel 1%) prior authorization

Coverage Criteria

Coding and Drug

Provider Actions and Requirements

Background

Definitions

Initial Therapy Criteria

Quantity Limits

Site of Care