Cambia (Diclofenac)

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Market Applicability Market DC GA KY MD NJ NY WA Applicable X X X X X X NA Cambia (diclofenac) Override(s) Approval Duration Prior Authorization 1 year Medications Cambia (diclofenac) packets for oral solution APPROVAL CRITERIA Requests for Cambia (diclofenac) may be approved if the following criteria is met: I. Individual has had trial (medication samples/coupons/discount cards are excluded from consideration as a trial) of and inadequate response or intolerance to two preferred generic non-steroidal anti-inflammatory drugs (NSAIDs), one of which must be a preferred generic diclofenac agent; AND II. Documentation has been provided which defines: A. The inadequate response or intolerance to two of the preferred oral NSAIDs, one of which must be a preferred generic diclofenac agent; Preferred oral NSAIDS: All generically available Ibuprofen (except Infants Advil 50mg/1.25 ML) Diclofenac Potassium Diclofenac Sodium Etodolac, Etodolac ER Fenoprofen Calcium Flurbiprofen Indomethacin Ketoprofen Ketorolac Tromethamine Meclofenamate Sodium Meloxicam Nabumetone Naproxen Sodium all generic formulations Naproxen Oxaprozin Piroxicam PAGE 1 of 2 08/19/2019 New Program Date 08/23/2017 This policy does not apply to health plans or member categories that do not have pharmacy benefits, nor does it apply to Medicare. Note that market specific restrictions or transition-of-care benefit limitations may apply. CRX-ALL-0432-19 Market Applicability Market DC GA KY MD NJ NY WA Applicable X X X X X X NA Sulindac Tolmetin Sodium AND B. The medical reason Cambia (diclofenac) is clinically necessary. State Specific Mandates State name Date effective Mandate details (including specific bill if applicable) N/A N/A N/A Key References: 1. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.: 2018. URL: http://www.clinicalpharmacology.com. Updated periodically. 2. DailyMed. Package inserts. U.S. National Library of Medicine, National Institutes of Health website. http://dailymed.nlm.nih.gov/dailymed/about.cfm. Accessed: June 14, 2018. 3. DrugPoints® System [electronic version]. Truven Health Analytics, Greenwood Village, CO. Updated periodically. 4. Lexi-Comp ONLINE™ with AHFS™, Hudson, Ohio: Lexi-Comp, Inc.; 2018; Updated periodically. PAGE 2 of 2 08/19/2019 New Program Date 08/23/2017 This policy does not apply to health plans or member categories that do not have pharmacy benefits, nor does it apply to Medicare. Note that market specific restrictions or transition-of-care benefit limitations may apply. CRX-ALL-0432-19 .

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Acute Renal Failure Associated with Diflunisal J. G. WHARTON D. 0
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