OBJECTIVES Multidrug-resistant tuberculosis (MDR-TB) is designated an orphan disease in Germany, where  about ~65 patients are infected with multidrug-resistant tuberculosis (MDR-TB). Regimens consisting of several drugs for up to 24 months are the current standard of care (SoC) for treatment of MDR-TB. The aim of this analysis is to evaluate the costs and effectiveness of adding bedaquiline (BDQ) to a background regimen (BR) of the SoC in a German healthcare context. METHODS A cohort based Markov model was used to estimate cost-effectiveness of bedaquiline plus background regimen (BDQ+BR) vs. BR alone for treatment of MDR- and XDR-TB (extensively drug resistant). The effectiveness of treatment was evaluated in QALYs, DALYs and life year gained (LYG). Inputs into the model were derived from a bedaquiline randomised, placebo controlled trial and from published literature. Drug costs (in 2014 euros) were taken from the German drug directory; a yearly discount rate of 3% was applied and a time horizon of 10 years was assumed. Sensitivity analyses were performed to evaluate the impact of model parameters. RESULTS For a base-case analysis with a cohort of 65 MDR-TB patients, adding bedaquiline to BR results in higher costs compared to BR alone (4,5 vs. 2,4 MM €), but yields better outcomes (66 QALYs gained). The incremental cost per QALY gained (ICER) was calculated as 33.357 €. For a cohort exclusively of XDR-TB patients, the ICER was calculated as 17.915 €. To evaluate the impact of model parameters, further sensitivity analyses were performed. CONCLUSIONS Adding bedaquiline to a background regimen of anti-TB drugs is cost-effective, probably even cost saving for patients with MDR- and XDR-TB, when compared to BR alone under different cost scenarios. Over a ten year period, cost savings were mostly achieved by lesser time of hospitalisation, although BDQ+BR drug costs are higher than BR alone.