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Limited Coverage Drugs - Special Authority Criteria
| Generic Name / Strength / Form |
| clotrimazole 1% 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 require further special authority consideration.
Online Forms (PDF)
Click on the link to complete a special authority request form.
PDF Format
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Last Revised: January 17, 2008
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