Limited Coverage Drugs - Econazole topical

Generic Name / Strength / Form

econazole topical

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 will not be eligible for coverage.

Special Authority Request Form(s)