Flector Patch® & Licart™ Topical – NC Standard

Restricted Product(s)

• Flector patch (diclofenac epolamine patch) 
• Licart (diclofenac epolamine) topical system

FDA Approved Use

• A nonsteroidal anti-inflammatory drug (NSAID) indicated for the topical treatment of acute pain due to minor strains, sprains, and contusions.

Criteria for Approval of Restricted Product(s)

1. The requested agent is Flector patch (diclofenac epolamine patch); AND 
   1. The patient is 6 years and older; OR 
2. The requested agent is Licart (diclofenac epolamine) topical system; AND 
   1. The patient is 18 years and older; AND 
3. The medication is being used for the relief of acute pain due to minor strains, sprains and contusions; AND 
4. The patient has had a failure of an adequate 1 week trial of an oral prescription NSAID for this condition; OR 
   1. The patient has an intolerance to oral NSAIDS; OR 
5. The patient cannot take solid oral dosage forms and is not currently taking any solid oral dosage forms; AND 
6. The patient will not be taking an oral NSAID (including COX-2 inhibitors) concurrently for the same condition; AND 
7. For formularies that exclude (non-formulary) the requested medication, Non-formulary Exception Criteria applies.
   
   Duration of Approval: 60 days

References

All information referenced is from FDA package insert unless otherwise noted below.

Drug Facts and Comparisons eAnswers. Wolters Kluwer. Accessed March 2011.

Flector Patch. DRUGDEX Evaluations. Micromedex 2.0. Thomson Reuters. March 2011.

Policy Implementation/Update Information

December 2024: Criteria update: Annual criteria review. Formatting changes only.
May 2020: Criteria update: Added Licart 1.3% topical system to the policy.
March 2019: Expanded indication update to include pediatrics age 6 years and older
September 2016: Reviewed for ASO Net Results and Essential formularies; non-formulary verbiage added. Updated length of oral NSAID trial to 1 week as intended.
June 2016: Reviewed and reformatted with no change to content
May 2012: Original utilization management criteria issued.