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

  PLUS

  diagnosis of a fungal infection of the lower extremities.
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.

Special Authority Request Form(s)