Limited Coverage Drugs - Fluconazole

Generic Name / Strength / Form

fluconazole oral

Special Authority Criteria

Approval Period

1. Immunocompromised patients.

OR

2. Exceptions on an individual basis for fungal infections resistant to first-line medications.

One day to indefinite

Practitioner Exemptions

  • Physicians specializing in treatment of HIV/AIDS patients

Special Notes

  • None

Special Authority Request Form(s)

Online Forms (PDF, 523KB)
Click on the link to complete a special authority request form.