Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
econazole 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
PLUS
diagnosis of a fungal infection of the lower extremities.

 Three months

Practitioner Exemptions

  • No practitioner exceptions

Special Notes

  • Details regarding patient's condition are required.
  • Compounded formulations containing this medication will not be eligible for coverage.

Online Forms (PDF)
Click on the link to complete a special authority request form.