Limited coverage criteria – Itraconazole

Last updated on March 18, 2025

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Generic name	itraconazole
Strength & form	100 mg capsule 10 mg/mL oral solution

Generic name

itraconazole

Strength & form

100 mg capsule

10 mg/mL oral solution

Special Authority criteria	Approval period
Immunocompromised patients	Up to indefinite
Pulse treatment for severe onychomycosis with functional disability PLUS Confirmed lab results for candida or dermatophyte infection	Three months

Special Authority criteria

Approval period

Immunocompromised patients

Up to indefinite

Pulse treatment for severe onychomycosis with functional disability

PLUS

Confirmed lab results for candida or dermatophyte infection

Three months

Practitioner exemptions

Physicians specializing in treatment of HIV/AIDS patients

Special notes

None

Special Authority request form(s)

Log in to eForms
HLTH 5328 – General Special Authority request (PDF, 656KB)

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