Limited Coverage Drugs – Chloroquine

Generic Name

chloroquine
Strength 200 mg, 250 mg
Form tablet

Special Authority Criteria

Approval Period

1. Treatment of extraintestinal amebiasis. Three week supply
OR
2. Rheumatoid arthritis or lupus. Indefinite

Practitioner Exemptions

Practitioners in the following specialty are not required to submit a Special Authority request for coverage:

  • Rheumatologists

Special Notes

  • Chloroquine for prevention of malaria is not an eligible PharmaCare benefit.

Special Authority Request Form(s)