WHA

SOLARAZE (diclofenac) 

SELF ADMINISTRATION - TOPICAL

Diagnosis considered for coverage:
  • Indicated for the topical treatment of actinic keratoses (AK). Sun avoidance is indicated during therapy
Coverage Criteria:

For diagnosis of actinic keratosis:

  • Quantity requested does not exceed 100 grams per 30 day supply, AND
  • Patient is 18 years of age or older, AND
  • Patient has a diagnosis of actinic keratosis as confirmed by chart note documentation, AND
  • Patient has failed or is not a good candidate for liquid nitrogen cryotherapy and surgical curettage, AND
  • Patient has tried and failed topical imiquimod 5% or fluorouracil 5%
Coverage Duration:
  • 3 months
Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information:
  • Recommended dose: apply to lesion areas twice daily for 60 days to 90 days
  • Lesions that do not respond to therapy should be carefully re-evaluated and management reconsidered
  • Contraindications:
    • Patients with a known hypersensitivity to diclofenac, benzyl alcohol, polyethylene glycol monomethyl ether 350 and/or hyaluronate sodium
    • In the setting of coronary artery bypass graft (CABG) surgery
  • Black Box Warnings:
    • Cardiovascular Thrombotic Events
  • Additional warning for heart failure and edema
  • Use with caution in patients with active gastrointestinal ulceration or bleeding and severe renal or hepatic impairments
  • Solaraze® should not be applied to open skin wounds, infections, or exfoliative dermatitis
  • Solaraze® should not be allowed to come in contact with the eyes
Policy Updates:
  • 06/05/2017 – Criteria reviewed
  • 10/12/2020 – Annual review. Format updated
  • 06/15/2021 – Criteria updated. Format updated. Added quantity limit, chart note documentation, and trial and failure of imiquimod
References:
  • Solaraze [package insert]. Melville (NY): PharmaDerm; 2016.

Last review date: June 15, 2021