Limited Coverage Drugs - Voriconazole

Generic Name / Strength / Form

voriconazole / 50 mg, 200 mg / tablet
voriconazole / 200 mg / injection

Criteria

Approval Period

  1. For continuation of hospital-initiated treatment of invasive aspergillosis

OR

  1. For continuation of hospital-initiated treatment of culture proven invasive candidiasis with documented resistance to fluconazole.

3 months

Practitioner Exemptions

  • None

Special Notes

  • PharmaCare does not provide coverage for community initiated treatment of invasive aspergillosis associated with HIV.

Special Authority Request Form(s)