Topical Diclofenac – Diclofenac 3% Gel Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Diclofenac 3% gel will be approved when BOTH of the following are met:

1. The patient has a diagnosis of actinic keratosis (AK)
   AND
2. The patient does NOT have any FDA labeled contraindications to the requested medication

Length of Approval: 3 months