Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
fluconazole oral

Criteria Approval Period
1. Immunocompromised patients.

OR

2. Exceptions on an individual basis for fungal infections resistant to first-line medications.

 One day to indefinite

Practitioner Exemptions

  • Physicians specializing in treatment of HIV/AIDS patients

Special Notes

  • None

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