Limited Coverage Drugs – Ciclopirox 1% topical

Generic Name ciclopirox
Strength 1%
Form topical cream, topical lotion

Special Authority Criteria

Approval Period

1. Diagnosis of diabetes

PLUS

diagnosis of a fungal infection of the lower extremities.

OR

2. Diagnosis of a circulatory condition

PLUS

diagnosis of a fungal infection of the lower extremities.

Three months

Practitioner Exemptions

  • No practitioner exceptions

Special Notes

  • Details regarding patient's condition is required.
  • Compounded formulations containing this medication require further special authority consideration.

Special Authority Request Form(s)