Quinine Sulfate Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Quinine sulfate will be approved when BOTH of the following are met:

1. The patient has ONE of the following diagnoses:

   1. Uncomplicated malaria
      OR
   2. Babesiosis
      OR
   3. 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

Length of Approval:

Malaria: 7 days

Babesiosis: 10 days

Other diagnoses: 12 months