Daraprim (pyrimethamine) — Highmark
Pneumocystis jirovecii pneumonia (primary prophylaxis)
Preferred products
- pyrimethamine (generic)
Initial criteria
- Member has a diagnosis of HIV (ICD-10: B20).
- Member will be using Daraprim (pyrimethamine) for primary prophylaxis of Pneumocystis jirovecii pneumonia (ICD-10: B59).
- Member has a 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