Phone: 504-849-4500, 225-346-6380, 1-800-631-8443
Fax: 504-849-6901

  • DICLOFENAC DIS 1.3%

    Prior Authorization only applies to members new to therapy?
    No

    Indications:
    All Part D medically-accepted Indications (FDA-approved and compendia-supported).

    Exclusion Criteria:


    Required Medical Information:
    Acute Pain: Topical treatment of acute pain due to one of the following: minor strain, sprain, contusion.

    Age Restrictions:


    Prescriber Restrictions:


    Coverage Duration:
    Plan year

    Other Criteria:


    If you are a provider, you can submit a prior authorization request online at https://professionals.optumrx.com.

    Updated: 09/2022

Last updated 10/02/2023