Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
ciprofloxacin / dexamethasone ear drops

Criteria Approval Period
For the diagnosis of:
  1. Acute otitis media with otorrhea through tympanostomy tube
    OR
  2. Acute otitis externa in the presence of a tympanostomy tube
    OR
  3. Acute otitis externa in the presence of known perforation of the tympanic membrane.

14 day supply
OR

Up to 3 months as requested
OR
  1. Failure or intolerance to an aminoglycoside antibiotic.

14 day supply
OR

Up to 3 months as requested

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • None

Forms