Limited coverage drugs – clotrimazole

Last updated on October 7, 2022
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

3 months

Practitioner exemptions

  • None

Special notes

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

Special Authority request form(s)