Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form

miconazole 2% topical

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 exemptions

Special Notes

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

Special Authority Request Form(s)

Online Forms (PDF, 524KB)
Click on the link to complete a special authority request form.