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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.
PDF Format
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Last Revised: June 21, 2006
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