Limited coverage criteria – loperamide

Last updated on April 15, 2025

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Generic name		loperamide
Strength & form		1 mg/5 mL liquid 2 mg tablet

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

Practitioner exemptions

Physicians specializing in the treatment of HIV/AIDS patients

Special notes

Details regarding patient's condition is 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 – loperamide

Generic name

Strength & form

Special Authority criteria

Approval period

Practitioner exemptions

Special notes

Special Authority request form(s)