Limited Coverage Drugs - diphenoxylate HCl-atropine sulfate

Generic Name

diphenoxylate HCIatropine sulfate

Strength
2.5-0.025 mg

Form
tablet


Special Authority Criteria


Approval Period


Treatment of diarrhea due to a specified chronic illness.
 

Indefinite

Practitioner Exemptions

  • No practitioner exceptions.

Special Notes

  • Details regarding patient's condition are required.

Special Authority Request Form(s)