Limited coverage criteria – diphenoxylate HCl-atropine sulfate

Last updated on March 17, 2025

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Generic name	diphenoxylate HCI-atropine sulfate
Strength	2.5-0.025 mg tablet

Special Authority criteria	Approval period
Treatment of diarrhea due to a specified chronic illness	Indefinite

Practitioner exemptions

None

Special notes

Details regarding patient's condition are required

Special Authority request form(s)

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HLTH 5328 – General Special Authority request (PDF, 656KB)

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Limited coverage criteria – diphenoxylate HCl-atropine sulfate

Generic name

Strength

Special Authority criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)