Limited Coverage Drugs - Clotrimazole

Generic Name

clotrimazole

Strength

1%
Form cream 

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 are required.
  • Compounded formulations containing this medication require further special authority consideration.

Special Authority Request Form(s)