Limited coverage drugs – clioquinol topical

Last updated on August 20, 2024
Generic name / Strength / Form
clioquinol/flumethasone / 3 % - 0.02 % / cream
clioquinol/hydrocortisone / 3 % - 1 % / cream

Special Authority 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

3 months

Practitioner exemptions

  • None

Special notes

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

Special Authority request form(s)