Daraprim (pyrimethamine) — Highmark
Cystoisosporiasis (isosporiasis)
Preferred products
- pyrimethamine (generic)
Initial criteria
- Member has a diagnosis of acute cystoisosporiasis infection (ICD-10: A07.3) OR will be using Daraprim (pyrimethamine) for secondary prophylaxis/chronic maintenance of cystoisosporiasis infection (ICD-10: A07.3) AND CD4 count < 200 cells/mm3.
- Member has experienced therapeutic failure, contraindication, or intolerance to trimethoprim-sulfamethoxazole (TMP-SMX).
- If the request is for brand Daraprim, member has experienced therapeutic failure or intolerance to generic pyrimethamine.
Reauthorization criteria
- Prescriber attests that the member has experienced positive clinical response to therapy.
Approval duration
12 months