Prior Authorization Criteria for Approval

Atovaquone will be approved when BOTH of the following are met:

1. ONE of the following: 
   1. BOTH of the following: 
      1. ONE of the following: 
         1. The patient has a diagnosis of mild-to-moderate Pneumocystis jirovecii pneumonia OR 
         2. The patient is using the requested medication for prevention of Pneumocystis jirovecii pneumonia AND 
      2. ONE of the following: 
         1. The patient has an intolerance or hypersensitivity to trimethoprim/sulfamethoxazole (TMP/SMX) OR 
         2. The patient has an FDA labeled contraindication to trimethoprim/sulfamethoxazole (TMP/SMX) OR 
   2. The patient has an indication that is supported in CMS approved compendia for the requested medication AND 
2. ONE of the following: 
   1. The requested quantity (dose) does NOT exceed the program quantity limit OR 
   2. BOTH of the following: 
      1. The requested quantity (dose) is greater than the program quantity limit AND 
      2. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months