Limited coverage criteria – clioquinol topical

Last updated on February 28, 2025

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Generic name	clioquinol/flumethasone clioquinol/hydrocortisone
Strength & form	clioquinol/flumethasone: 3% - 0.02% cream clioquinol/hydrocortisone: 3% - 1% cream

Generic name

clioquinol/flumethasone

clioquinol/hydrocortisone

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

Special Authority criteria

Approval period

1. Diagnosis of diabetes

PLUS

Diagnosis of a fungal infection of the lower extremities

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

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5328 - General Special Authority request (PDF, 656KB)

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