Topical Agents
Miscellaneous

Brand/Generic Name Dosage/Strength Status Restrictions Notes Relative Cost
Pennsaid
Diclofenac Sodium		 Solution   notreimb.gif (545 bytes)  

Not Applicable

Key for Product(s) Listed Above
Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary
(Third tier coverage applies for selected plans)		 Not Reimbursed
Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available
Notes $Relative cost compared to others in category Specialty distribution for selected plans

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