Pretomanid — Highmark
treatment-intolerant multidrug resistant (MDR) pulmonary tuberculosis
Initial criteria
- Diagnosis of pulmonary tuberculosis (ICD-10: A15.0) classified as treatment intolerant or nonresponsive multidrug resistant (MDR)
- Therapeutic failure, contraindication, or intolerance to isoniazid AND to a rifamycin antibiotic (for example rifampin, rifabutin, or rifapentine)
- Pretomanid is used as part of a combination regimen with BOTH bedaquiline AND linezolid
Reauthorization criteria
- Member has experienced positive clinical response and requires additional antimicrobial therapy
Approval duration
12 months