Limited coverage drugs – Itraconazole

Last updated on August 27, 2024

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

Criteria	Approval period
1. Immunocompromised patients.	1. Up to indefinite
OR 2. Pulse treatment for severe onychomycosis with functional disability PLUS confirmed lab results for candida or dermatophyte infection.	2. Three months

Criteria

Approval period

1. Immunocompromised patients.

1. Up to indefinite

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

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Special Authority Request (HLTH 5328)(PDF)

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Limited coverage drugs – Itraconazole

Practitioner exemptions

Special notes

Special Authority request form