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Diclofenac 3% Gel – Net Results
Restricted Product(s):
- Diclofenac 3% gel
FDA Indication:
- For the topical treatment of actinic keratoses (AK) in conjunction with sun avoidance.
Criteria for Approval of Restricted Product(s):
- The patient has been diagnosed with actinic keratoses; AND
- The patient has tried and failed or has a clinical contraindication/intolerance to generic imiquimod; AND
- For products that require Value PA, refer to the Value PA UM Criteria.
Duration of Approval: 180 days
References:
All information referenced is from FDA package insert unless otherwise noted below.
Policy Implementation/Update Information:
Criteria and treatment protocols are reviewed annually by the Blue Cross NC P&T Committee, regardless of change. This policy is reviewed in Q1 annually.
November 2023: Criteria update: Updated terminology from Medical Necessity PA to Value PA.
September 2021: Criteria update: Removed Klisryi from policy. Created Net Results only policy.
Feb 2021: Criteria update: Added new ointment Klisyri to the policy.
May 2020: Criteria update: Annual criteria review. Removed recommended alternatives. Updated FDA indication.
May 2017: Reformatted criteria; Non-formulary exception verbiage added.
April 2016: Policy Originated
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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