Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form

itraconazole

Criteria

Approval Period

1. Immunocompromised patients.

1. Indefinite

OR

2. Pulse treatment for severe onychomycosis with functional disability
PLUS
confirmed lab results for candida or dermatophyte infection.

2. Three months

Practitioner Exemptions

  • Physicians specializing in treatment of HIV/AIDS patients

Special Notes

  • None

Special Authority Request Form(s)

Online Forms (PDF, 524KB)
Click on the link to complete a special authority request form.