Limited Coverage Drugs – Chloroquine
|
Generic Name |
chloroquine |
| Strength | 200 mg, 250 mg |
| Form | tablet |
|
Special Authority Criteria |
Approval Period |
| 1. Treatment of extraintestinal amebiasis. | Three week supply |
| OR | |
| 2. Rheumatoid arthritis or lupus. | Indefinite |
Practitioner Exemptions
Practitioners in the following specialty are not required to submit a Special Authority request for coverage:
- Rheumatologists
Special Notes
- Chloroquine for prevention of malaria is not an eligible PharmaCare benefit.
