Limited Coverage Drugs - Special Authority Criteria
Generic Name / Strength / Form
miconazole 2% topical
|1. Diagnosis of diabetes
diagnosis of a fungal infection of the lower extremities.
2. Diagnosis of a circulatory condition
- No practitioner exemptions
- Details regarding patient's condition are required.
- Compounded formulations containing this medication require further special authority consideration.
Special Authority Request Form(s)
Online Forms (PDF, 524KB)
Click on the link to complete a special authority request form.