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Limited coverage criteria – clotrimazole

Last updated on February 28, 2025

Generic name

 clotrimazole

Strength & form

 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 require further special authority consideration

Special Authority request form