Pyrimethamine Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Pyrimethamine will be approved when ALL of the following are met:

1. The patient has an FDA labeled indication or an indication that is supported in CMS approved compendia for the requested medication
   AND
2. The patient does NOT have any FDA labeled contraindications to the requested medication
   AND
3. The requested dose is within FDA labeled dosing or supported in CMS approved compendia dosing for the requested indication

Length of Approval: 6 months