Standard Health Pals Formulary
Diclofenac Sodium Topical Gel 1% (Generic for Voltaren)
Coverage Level – 100%
Copay – $0
Limitations – No more than 90 days’ supply; Maximum 100 grams in 30 days; Maximum 300 grams in 90 days
Restrictions – Health Pals Mail Order Pharmacy Network
Comments – Generic for Voltaren