Reimbursement/Insurance Documents

Licart Reimbursement Guide

Acertis has developed a reimbursement guide to support healthcare professionals (HCPs) as they navigate coverage, coding, and insurance coverage for Licart® (diclofenac epolamine) topical system 1.3%. The information in this reimbursement guide is intended solely as a resource to assist the staff in physicians’ offices with certain insurance-related questions for Licart.

Sample Letters of Medical Necessity and Appeal for Insurance Provider

Provided below are downloadable templates for HCPs to reference and utilize at their convenience for insurance providers on behalf of Licart. These are not to be sent as is; fill in patient information as needed.

» Download Sample Letter of Medical Necessity
» Download Sample Letter of Appeal

ICD-10 Codes

» Download Licart ICD-10 Codes

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INDICATIONS AND USAGE

LICART contains diclofenac epolamine, which is a nonsteroidal anti-inflammatory drug (NSAID), and is indicated for the topical treatment of acute pain due to minor strains, sprains, and contusions.

IMPORTANT SAFETY INFORMATION

WARNING: RISK OF SERIOUS CARDIOVASCULAR and GASTROINTESTINAL EVENTS

Cardiovascular Thrombotic Events

  • Nonsteroidal anti-inflammatory drugs (NSAIDs) cause an increased risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke, which can be fatal. This risk may occur early in the treatment and may increase with duration of use.
  • LICART is contraindicated in the setting of coronary artery bypass graft (CABG) surgery.

Gastrointestinal Bleeding, Ulceration, and Perforation

  • NSAIDs cause an increased risk of serious gastrointestinal (GI) adverse events, including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients and patients with a prior history of peptic ulcer disease and/or GI bleeding are at greater risk for serious GI events.

CONTRAINDICATIONS

LICART is contraindicated in the following patients:

  • Known hypersensitivity to diclofenac or any components of the drug product.
  • History of asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs.
  • In the setting of CABG surgery.
  • For use on non-intact or damaged skin.

WARNINGS AND PRECAUTIONS

  • Hepatotoxicity: Inform patients of warning signs and symptoms of hepatotoxicity. Discontinue if abnormal liver tests persist or worsen or if clinical signs and symptoms of liver disease develop.
  • Hypertension: Patients taking some antihypertensive medications may have impaired response to these therapies when taking NSAIDs. Monitor blood pressure.
  • Heart Failure and Edema: Avoid use of LICART in patients with severe heart failure unless benefits are expected to outweigh risk of worsening heart failure.
  • Renal Toxicity: Monitor renal function in patients with renal or hepatic impairment, heart failure, dehydration, or hypovolemia. Avoid use of LICART in patients with advanced renal disease unless benefits are expected to outweigh risk of worsening renal function.
  • Anaphylactic Reactions: Seek emergency help if an anaphylactic reaction occurs.
  • Exacerbation of Asthma Related to Aspirin Sensitivity: LICART is contraindicated in patients with aspirin-sensitive asthma. Monitor patients with preexisting asthma (without aspirin sensitivity).
  • Serious Skin Reactions: Discontinue LICART at first appearance of skin rash or other signs of hypersensitivity.
  • Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS): Discontinue and evaluate clinically.
  • Fetal Toxicity: Limit use of NSAIDs, including LICART, between about 20 to 30 weeks in pregnancy due to the risk of oligohydramnios/fetal renal dysfunction. Avoid use of NSAIDs in women at about 30 weeks' gestation and later in pregnancy due to the risks of oligohydramnios/fetal renal dysfunction and premature closure of the fetal ductus arteriosus.
  • Hematologic Toxicity: Monitor hemoglobin or hematocrit in patients with any signs or symptoms of anemia.

ADVERSE REACTIONS

Most common adverse reactions for LICART are application site pruritus and other application site reactions.
To report SUSPECTED ADVERSE REACTIONS, contact IBSA Pharma Inc. at: 1-800-587-3513 or FDA at 1-800-FDA-1088 or fda.gov/medwatch.
For Full Prescribing Information, visit licart.com/wp-content/uploads/2023/10/Licart-Full-Prescribing-Information_2024.pdf.

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