Limited coverage drugs – clioquinol topical
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| 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 PLUS Diagnosis of a fungal infection of the lower extremities |
3 months |
Practitioner exemptions
- None
Special notes
- Details regarding patient's condition are required
- Compounded formulations containing this medication will not be eligible for coverage
