Pretomanid — Highmark

extensively drug resistant (XDR) pulmonary tuberculosis

Initial criteria

Diagnosis of pulmonary tuberculosis (ICD-10: A15.0) classified as pre-extensively drug resistant (pre-XDR) or extensively drug resistant (XDR)
Therapeutic failure, contraindication, or intolerance to isoniazid AND to a rifamycin antibiotic (for example rifampin, rifabutin, or rifapentine)
Therapeutic failure, contraindication, or intolerance to ONE of the following: (a) a fluoroquinolone antibiotic (for example levofloxacin, moxifloxacin) OR (b) amikacin, kanamycin, or capreomycin
Pretomanid is used as part of a combination regimen with BOTH bedaquiline AND linezolid

Member has experienced positive clinical response and requires additional antimicrobial therapy

12 months