Pharmacy Prior Authorization Criteria

Skin Cancer Agents

Indications for Prior Authorization

diclofenac sodium gel 3%

• For diagnosis of Actinic keratosis
  Indicated for the topical treatment of actinic keratoses. Sun avoidance is indicated during therapy.

Criteria

diclofenac sodium 3% gel

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure, contraindication, or intolerance to one of the following generics:
• imiquimod
• fluorouracil

P & T Revisions

2024-03-25, 2023-04-04, 2022-04-05, 2021-06-07, 2021-05-11, 2020-04-29

References

1. American Academy of Dermatology. Actinic Keratosis: diagnosis and treatment. https://www.aad.org/public/diseases/scaly-skin/actinic-keratosis#treatment. Accessed March 25, 2024.
2. Diclofenac sodium gel 3% Prescribing Information. Fort Collins, CO: Tolmar Inc.; June 2021.

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Revision History

• 2024-03-25: 2024 annual review. Updated references.
• 2023-04-04: Annual review - picato discontinued and will be obsolete 4/8/2023 - removed product. Updated background and references.
• 2022-04-05: Annual review - added diagnosis statement and updated references.
• 2021-06-07: update guideline name, no changes to criteria
• 2021-05-11: Annual Review & Added to EHB Formulary
• 2020-04-29: Annual Review

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