Limited Coverage Drugs – Ciprofloxacin / dexamethasone

Generic Name ciprofloxacin / dexamethasone
Strength 0.3 %-0.1%
Form ear drops

Special Authority Criteria

Approval Period

For the diagnosis of:

  1. Acute otitis media with otorrhea through tympanostomy tube

    OR

  2. Acute otitis externa

14 day supply

OR

Up to 3 months as requested

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

  • None

Special Authority Request Form(s)