Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
loperamide

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.

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