Limited coverage drugs – miconazole

Last updated on August 23, 2024

Generic name

miconazole
Strength 2% topical; 100 mg, 400 mg; 1200 mg
Form Cream; Suppository

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 exemptions.

Special notes

  • Details regarding patient's condition are required.
  • Compounded formulations containing this medication require further Special Authority consideration.

Special Authority request form(s)