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Diclofenac 1.5% Solution Prior Authorization Criteria - Medicare Part D
Medicare Utilization Management Policy
Version Date: 01/01/2025

Prior Authorization Criteria for Approval

Diclofenac 1.5% solution will be approved when BOTH of the following are met:

  1. ONE of the following:
    1. The patient has an FDA labeled indication for the requested medication
      OR
    2. The patient has an indication that is supported in CMS approved compendia for the requested medication
      AND
  2. The patient does NOT have any FDA labeled contraindications to the requested medication

Length of Approval:

Acute Pain: 3 months

All Other Diagnoses: 12 months
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