Tuberculosis agents prior authorization
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Prior authorization requirements for tuberculosis agents (including Pretomanid and Sirturo) for members under CareOregon; governs approval criteria and documentation needed for coverage of multidrug-resistant active tuberculosis regimens.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial therapy / Prior authorization criteria
Covered when ALL of the following are met
Main criteria
ONE of the following
- Option A: Prescribed by or in consultation with an infectious disease specialist
- Option B: Prescribed in consultation with a state or county tuberculosis program
- Option C: Submission of medical records (e.g., chart note) confirming multidrug-resistant active TB
Covered when ALL of the following are met: 1) documentation of a diagnosis of active tuberculosis infection; and 2) treatment is prescribed by or in consultation with an infectious disease specialist and in consultation with a state or county tuberculosis program, with submission of medical records (for example, a chart note) confirming multidrug-resistant active TB. Approval length is regimen-dependent at 24 or 26 weeks.
Prior authorization is required for the specified tuberculosis agents listed in this guideline (including Pretomanid and Sirturo). Prescriptions must be by or in consultation with an infectious disease specialist and in consultation with the appropriate state or county tuberculosis program. Supporting clinical documentation must be submitted to demonstrate the member has multidrug-resistant active TB as described above; absence of these required documents or consultations may result in denial of the request.
Coding and Approval Length
| Pretomanid | Pretomanid |
| Sirturo | Sirturo |
Provider Actions and Requirements
Prior authorization required for Pretomanid and Sirturo
Prior authorization is required for Pretomanid and Sirturo. Approval length is 24 or 26 weeks depending on the regimen; prescriptions must be by or in consultation with an infectious disease specialist and in consultation with a state or county tuberculosis program.
- Approval length: 24 or 26 weeks depending on regimen
- Prescription must be by or in consultation with an infectious disease specialist
- Prescription must be in consultation with a state or county tuberculosis program
Coordinate specialist and public health consultation
Prescriptions for these agents must be coordinated with infectious disease specialists and the applicable state or county tuberculosis program as part of the prior authorization process.
- Coordinate prescribing with an infectious disease specialist
- Document consultation with the state or county tuberculosis program
Submit medical records confirming multidrug‑resistant active TB
Submit medical records (for example, a chart note) that confirm the member has multidrug-resistant active tuberculosis as part of the prior authorization request.
- Include chart notes or equivalent documentation confirming multidrug-resistant active TB
Missing documentation or consultations may lead to denial
A lack of the required documentation confirming multidrug-resistant active TB or absence of consultation with an infectious disease specialist or state/county tuberculosis program may result in denial of the request.
- Missing chart notes confirming multidrug-resistant active TB risks denial
- No documented infectious disease or TB program consultation risks denial
Background
This policy addresses prior authorization requirements for agents used to treat active tuberculosis, with specific emphasis on regimens for multidrug-resistant active TB. Management of these cases generally requires specialist oversight and coordination with public health TB programs. The guideline notes approval durations are regimen-dependent (24 or 26 weeks) and that clinical records and consultations must be provided to support coverage decisions.
Definitions
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