Limited Coverage Drugs - Itraconazole

Generic Name Strength Form
itraconazole 100 mg capsule
10 mg/mL oral solution



Approval Period

1. Immunocompromised patients.

1. Indefinite


2. Pulse treatment for severe onychomycosis with functional disability
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