Limited Coverage Drugs – chloroquine

Generic Name

chloroquine

Strength

250 mg

Form

tablet

Special Authority Criteria

Approval Period

  1. Treatment of extraintestinal amebiasis

Three-week supply

OR
  1. Treatment of 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.

Special Authority Request Form(s)