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Prior Authorization Protocol
PENNSAIDR 2% (diclofenac sodium topical solution)


HNMC
Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.
  1. FDA Approved Indications:
    • For the treatment of the pain of osteoarthritis of the knee(s)
  2. Health Net Approved Indications and Usage Guidelines:
    • The indication is FDA approved or standard pharmacopeias (e.g. DrugDex) support efficacy and safety
    AND
    • Failure or clinically significant adverse effects to TWO oral generic nonsteroidal anti-inflammatory drug (NSAID)
  3. Coverage is Not Authorized For:
    • Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
  4. General Information:
    This field intentionally left blank.
  5. Therapeutic Alternatives:
    Drug Dosing Regimen Dose Limit/ Maximum Dose

    Oral NSAIDs


    diclofenac (VoltarenR)




    50 mg PO TID




    150 mg/day

    etodolac (LodineR)

    400-500 mg PO BID

    1200 mg/day

    fenoprofen (NalfonR)

    400 mg PO TID to QID

    3200 mg/day

    ibuprofen (MotrinR)

    400 - 800 mg PO TID to QID

    3200 mg/day

    indomethacin (IndocinR)

    25 - 50 mg PO BID to TID

    200 mg/day

    indomethacin SR (Indocin SRR)

    75 mg PO QD to BID

    150 mg/day

    ketoprofen (OrudisR)

    25-75 mg PO TID to QID

    300 mg/day

    meloxicam (MobicR)

    7.5 mg -15 mg PO QD

    15 mg/day

    naproxen (NaprosynR)

    250 - 500 mg PO BID

    1500 mg/day

    naproxen sodium (AnaproxR, Anaprox DSR)

    275 - 550 mg PO BID

    1650 mg/day

    oxaprozin (DayproR)

    600 - 1200 mg PO BID

    1800 mg/day

    piroxicam (FeldeneR)

    10 - 20 mg PO QD

    20 mg/day

    salsalate (DisalcidR)

    500 - 750 mg PO TID, titrated up to 3000 mg QD

    3000 mg/day

    sulindac (ClinorilR)

    150 mg - 200 mg PO BID

    400 mg/day

    tolmetin DS (Tolectin DSR)

    400 mg PO TID, titrated up to 1800 mg QD

    1800 mg/day

    * Requires Prior Authorization
  6. Recommended Dosing Regimen and Authorization Limit:
    Drug Dosing Regimen Authorization Limit

    Pennsaid 2%

    40 mg (2 pump actuations) BID on each painful knee

    Length of Benefit

  7. Product Availability:
    Topical solution: 2% (112 g bottle)
  8. References:
    1. Pennsaid [Prescribing Information]. Deerfield, IL: Horizon Pharma USA Inc.; January 2015.
The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.