Limited coverage drugs – miconazole

Last updated on August 23, 2024

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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

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.

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)

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5328 Special Authority Request Form (PDF)

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Limited coverage drugs – miconazole

Practitioner exemptions

Special notes

Special Authority request form(s)