Diagnosis: Osteoarthritis.
Treatment: Formulary exception for Pennsaid, Pre-service.
The insurer denied the Formulary exception for Pennsaid, Pre-service.
The denial is overturned.

The patient is a female with osteoarthritis/back pain. She has been prescribed PennSaid (Diclofenac Na [sodium] solution). The request denied as the formulary alternatives have not been tried and failed. Per the attached formulary requirements, three or more alternatives must be tried and failed.

Yes, the health plan should cover the Formulary exception for Pennsaid.
The patient is a female with osteoarthritis/back pain, who has been prescribed PennSaid (Dicolfenac Na [sodium] solution). The request denied as the formulary alternatives have not been tried and failed. The patient has failed Voltaren gel and over the counter creams. Per the attached formulary requirements, three or more alternatives must be tried and failed. Attached documentation shows that the patient has failed 3 or more formulary alternatives, which include diclofenac gel, Diclofenac sodium 1.5%, oral NSAIDS including Mobic, Naproxyn and Diclofenac. Given the above, the formulary criteria has been met, and all reasonable alternatives have been tried. All alternatives have been ineffective. Therefore, it cannot be determined if the requested medication would be ineffective for the patient, or effective or more effective than the formulary alternatives, as its base compound is the same. However, the formulary alternatives have been failed, and given that Voltaren gel has been tolerated, it is unlikely the patient would have adverse effects from the formulary preferred medication.