ZIPSOR (diclofenac)
SELF ADMINISTRATION - Oral
Indications for Prior Authorization:
- Indicated for relief of mild to moderate acute pain in adults (18 years of age or older)
Patients must meet the following criteria for the indication(s) above:
- Used for the relief of mild to moderate acute pain, AND
- Patient is 18 years of age or older, AND
- Chart note documentation is provided and confirms: patient has tried and failed two preferred generic prescription strength oral NSAIDs (nonsteroidal antiinflammatory drugs), one of the two must be generic Diclofenac tablets OR there is a medically appropriate reason why generic alternatives cannot be tried
Dosing:
- 25 mg four times a day
- Patients with hepatic disease may require reduced doses of Zipsor® compared to patients with normal hepatic function.
Last review date: July 17, 2018