Limited Coverage Drugs - Special Authority Criteria
Generic Name / Strength / Form |
|
miconazole 2% topical |
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 exemptions
Special Notes
- 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.