Orthopedic/Musculoskeletal - Knee Problem/Pain
Pharmacy/Prescription Drugs

The patient is a female with a history of chronic right knee pain, back pain from degenerative thoracic and lumbar disc disease, and iron deficiency. She is requesting coverage for Pennsaid (diclofenac topical), which is noted by her provider to be effective whereas the multiple other formulary drugs were not.

The health plan's determination is overturned.

In the documentation provided for review it was noted by the patient's provider that she has tried all of the formulary alternatives, and that they have been ineffective compared to the requested Pennsaid (diclofenac topical). The medical records reveal that the patient has been prescribed the Pennsaid (diclofenac topical) more than 3 years ago and that she has been taking it all along. In addition, it is reasonable to conclude that considering the patient's history of iron deficiency, the topical Pennsaid would be much less likely to cause serious side effects versus the oral agents. The formulary oral agents would likely have more adverse effects.