Sutter Health Plus
Pennsaid (diclofenac sodium)
Drugs for the Skin : Drugs for the Skin

  • For FAX form click HERE
    Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
     Log in to Surescripts
     Log in to CoverMyMeds; For details on drug coverage click  HERE;
  • Step Therapy: ST_APPLIES
  • Antiviral: Hepatitis C (HCV):
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    History of Substance Abuse: No
    If History of Substance Abuse, Drug Abstinence Duration: N/A
    If History of Substance Abuse, Appropriate Clean Drug Screen: No
    Policy Contains a Once in a Lifetime Restriction: No
    Co-Infection with Hepatitis B Prohibited in the Policy: No
    Extra-hepatic Disease Prohibited in Policy: No
    Treatment Duration Extended for Hepatocellular Carcinoma: No
    Concomitant Therapy with RBV: No
    Concomitant Therapy with RBV + IFN: No
    Concomitant Therapy with Daklinza: No
    Concomitant Therapy with Sovaldi: No
    Patient Must Not Have Been Previously Treated With a NS3-4A: No
    Patient Must Not Have Been Previously Treated With a NS-5A: No
    Fibrosis Score Required for Authorization: No

  • Quantity Limit: limit maximum 1 ML PER 30 day(s)
  • Prior Authorization: PA_APPLIES