diclofenac sodium external

1 % — Gel

Antineoplastics, Other

Also known as: diclofenac sodium external gel 3 % Diclofenac Sodium External Gel
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Checked: 18 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Essential + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Essential + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Gold Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Premier + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Bronze Signature + No Referrals Tier 2 - Generic — — ✓ QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals Tier 2 - Generic — — ✓ QL
Source: CMS QHP JSON  ·  Formulary date: Jun 10, 2026  ·  Checked: 18 hours, 2 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Longevity Health Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 100 per 28 days PA | QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) Tier 1 - Preferred Generic — ✓ ✓ 300 per 30 days ST | QL
Liberty Medicare Dual Plan (HMO D-SNP) Tier 1 - Preferred Generic ✓ — ✓ 100 per 30 days PA | QL
Liberty Medicare Advantage Nursing Home Plan (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 100 per 30 days PA | QL
PruittHealth Premier (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 100 per 30 days PA | QL
NHC Advantage (HMO I-SNP) Tier 1 - Preferred Generic ✓ — ✓ 100 per 30 days PA | QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) Tier 1 - Preferred Generic — ✓ ✓ 300 per 30 days ST | QL
Provider Partners North Carolina Community Plan (HMO I-SNP) Tier 1 - Preferred Generic — ✓ ✓ 300 per 30 days ST | QL
Senior Care (HMO I-SNP) Tier 2 - Generic ✓ — ✓ 100 per 30 days PA | QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) Tier 2 - Generic — — — None
Troy Medicare (HMO) Tier 2 - Generic — — — None
Liberty Medicare Advantage (HMO C-SNP) Tier 2 - Generic ✓ — ✓ 100 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP) Tier 2 - Generic — — — None
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H1036-137 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus SNP-DE H1036-167 (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H1036-233 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Humana Dual Select H1036-307 (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus Giveback H1036-318 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus SNP-DE H1036-331 (HMO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H1036-335 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
HumanaChoice Giveback H5216-017 (PPO) Tier 3 - Preferred Brand ✓ — — PA
HumanaChoice H5216-211 (PPO) Tier 3 - Preferred Brand ✓ — — PA
Humana Full Access H5525-034 (PPO) Tier 3 - Preferred Brand ✓ — — PA
HumanaChoice Giveback H5525-035 (PPO) Tier 3 - Preferred Brand ✓ — — PA
HumanaChoice SNP-DE H5525-036 (PPO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
HumanaChoice H5525-049 (PPO) Tier 3 - Preferred Brand ✓ — — PA
HumanaChoice H5525-050 (PPO) Tier 3 - Preferred Brand ✓ — — PA
HumanaChoice H5525-070 (PPO) Tier 3 - Preferred Brand ✓ — — PA
Humana Dual Select H5525-072 (PPO D-SNP) Tier 3 - Preferred Brand ✓ — — PA
HumanaChoice H5525-083 (PPO) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H6622-025 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H6622-026 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Humana Dual Select H6622-027 (HMO-POS D-SNP) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H6622-057 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H6622-060 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Plus H6622-061 (HMO-POS) Tier 3 - Preferred Brand ✓ — — PA
Humana Gold Choice H8145-004 (PFFS) Tier 3 - Preferred Brand ✓ — — PA
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) Tier 4 - Non-Preferred — ✓ ✓ 300 per 30 days ST | QL
AARP Medicare Advantage Giveback from UHC NC-13 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0012 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0011 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0009 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0008 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
UHC Dual Complete NC-D001 (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
UHC Nursing Home Plan NC-F001 (PPO I-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0007 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0022 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0021 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0019 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0017 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0016 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0004 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0001 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage Access from UHC NC-23 (PPO) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
UHC Dual Complete NC-S2 (PPO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
UHC Dual Complete NC-S001 (PPO D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
Erickson Advantage Signature (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
Erickson Advantage Guardian (HMO-POS I-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
Erickson Advantage Freedom (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
Erickson Advantage Liberty (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
UHC Complete Care NC-25 (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
UHC Complete Care NC-27 (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
UHC Complete Care NC-28 (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
Erickson Advantage Champion (HMO-POS C-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-26 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-24 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
UHC Dual Complete NC-S3 (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage from UHC NC-0015 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
UHC Dual Complete NC-V001 (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
AARP Medicare Advantage Giveback from UHC NC-14 (HMO-POS) Tier 4 - Non-Preferred ✓ — ✓ 100 per 30 days PA | QL
Blue Medicare PPO Enhanced (PPO) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Essential Plus (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Enhanced (HMO-POS) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Choice (HMO) Tier 4 - Non-Preferred ✓ — — PA
Blue Medicare Essential (HMO) Tier 4 - Non-Preferred ✓ — — PA
Experience Health Medicare Advantage (HMO) Tier 4 - Non-Preferred ✓ — — PA
Healthy Blue + Medicare (HMO-POS D-SNP) Tier 4 - Non-Preferred ✓ — — PA
HealthTeam Advantage Plan I (PPO) Tier 4 - Non-Preferred — ✓ ✓ 300 per 30 days ST | QL
HealthTeam Advantage Plan II (PPO) Tier 4 - Non-Preferred — ✓ ✓ 300 per 30 days ST | QL
HealthTeam Advantage Vitality Plan (PPO) Tier 4 - Non-Preferred — ✓ ✓ 300 per 30 days ST | QL
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