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Limited coverage criteria – miconazole

Last updated on March 19, 2025

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Generic name		miconazole
Strength & form		2% topical 100 mg/400 mg/1200 mg cream/suppository

Special Authority criteria	Approval period
For the treatment of fungal infection of the lower extremities in patients who have a diagnosis of: Diabetes OR A circulatory condition AND A diagnosis of a fungal infection of the lower extremities	Three months

Special Authority criteria

Approval period

For the treatment of fungal infection of the lower extremities in patients who have a diagnosis of:

Diabetes

A circulatory condition

AND

A diagnosis of a fungal infection of the lower extremities

Three months

Practitioner exemptions

None

Special notes

Details regarding patient's condition are required
Compounded formulations containing this medication require further Special Authority consideration

Special Authority request form(s)

Log in to eForms
HLTH 5328 - General Special Authority request (PDF, 656KB)

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