Daraprim (pyrimethamine) — Highmark

Preferred products

• pyrimethamine (generic)

Initial criteria

• Member has a diagnosis of acute Toxoplasmosis gondii infection (ICD-10: B58) AND if the request is for brand Daraprim, member has experienced therapeutic failure or intolerance to generic pyrimethamine.
• OR Member will be using Daraprim (pyrimethamine) for primary prophylaxis of Toxoplasmosis gondii infection (ICD-10: B58) AND all of the following: CD4 count < 100 cells/mm3; Toxoplasma IgG positive; therapeutic failure, intolerance, or contraindication to trimethoprim-sulfamethoxazole (TMP-SMX); AND if request is for brand Daraprim, therapeutic failure or intolerance to generic pyrimethamine.
• OR Member will be using Daraprim (pyrimethamine) for secondary prophylaxis/chronic maintenance of Toxoplasmosis gondii infection (ICD-10: B58) to prevent relapse AND all of the following: CD4 count < 200 cells/mm3; AND if request is for brand Daraprim, 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