Limited Coverage Drugs – Clioquinol Topical
Generic Name / Strength / Form |
---|
clioquinol/flumethasone / 3% - 0.02% / cream |
clioquinol/hydrocortisone / 3% - 1% / 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 |
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.