CurrentAvMedPolicy N/A

Pharmacy prior authorization and step-edit for Emverm (mebendazole)

Form and criteria for prior authorization/step-edit requests for mebendazole (Emverm) and related anthelmintic therapies for AvMed members; directs prescribers on required documentation and step therapy requirements for pinworm and hookworm infections.

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization and step-edit for Emverm (mebendazole)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization showing documented trial and failure of required pyrantel pamoate or CDC-recommended albendazole and include completed, signed request form with supporting chart notes or pharmacy paid claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Emverm per-fill limit

4albendazole per-fill limit

IncludedCDC dosing

RequiredStep therapy

Coverage Criteria

Initial authorization criteria

Covered when ALL of the following are met

Overall requirement: Member has documented diagnosis of pinworm or hookworm and prescriber-submitted prior authorization form with required fields and manual signature

Authorization limited to date of service; supporting documentation (lab results, diagnostics, chart notes, or pharmacy paid claims) must be provided or request may be denied

Pinworm step requirements

Option 1: At least 2 doses of a pyrantel pamoate product (initial dose and repeat dose 2 weeks later)
Verified by chart notes or pharmacy paid claims
Option 2: CDC-recommended dosage of albendazole

Policy Summary

PayerAvMed

PolicyPharmacy prior authorization and step-edit for Emverm (mebendazole)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Verified by chart notes or pharmacy paid claims

Hookworm step requirements

Option 1: At least 3 consecutive daily doses of a pyrantel pamoate product
Verified by chart notes or pharmacy paid claims
Option 2: CDC-recommended dosage of albendazole
Verified by chart notes or pharmacy paid claims

Step therapy and sample policy: Use of drug samples to initiate therapy does not satisfy step edit/preauthorization requirements

Previous therapies must be verified via pharmacy paid claims or submitted chart notes

Coverage of medications varies by member Plan. Not all drugs may be covered under every Plan; when a drug is non‑formulary for the member's Plan, the prescriber must provide documentation of medical necessity to support coverage determination.

The use of manufacturer or office samples to start therapy does not satisfy step‑edit or prior authorization requirements. Use of samples to initiate therapy does not meet step edit/ preauthorization criteria and will not be accepted as evidence of prior therapy for meeting step‑therapy requirements; prior treatments must be verified by chart notes or pharmacy paid claims.

Diagnosis and Billing Codes

Diagnosis codesICD-10

ICD code (if applicable)

Placeholder on form for diagnosis ICD code

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for Emverm (mebendazole). Approval is limited to the date of service and contingent on meeting the step-therapy criteria below. Submit the completed prior authorization/step-edit request form with all required documentation; incomplete or illegible forms may delay or result in denial of authorization.

Drug requested: Emverm (mebendazole)
Fax completed form to: 1-305-671-0200
Approval limited to date of service

Step Therapy

Step Therapy Requirement

Step therapy must be documented and met before Emverm will be approved. Requests must show trial and failure of the specified agents/dosing for the indicated diagnosis, verified by chart notes or pharmacy paid claims.

For Pinworm infection: trial and failure of ONE of the following — at least 2 doses of pyrantel pamoate (initial dose and a second dose 2 weeks later) OR CDC-recommended albendazole dosing.
For Hookworm infection: trial and failure of ONE of the following — at least 3 consecutive daily doses of pyrantel pamoate OR CDC-recommended albendazole dosing.
Use of samples to initiate therapy does NOT meet step-edit/preauthorization criteria.

Documentation Required

Required Form Fields and Supporting Documentation

The prescriber must complete and sign the authorization form. Required fields and supporting documentation must be included with the request; missing elements may delay or cause denial.

Prescriber must sign and clearly print name (preprinted stamps not acceptable); signature must be manual.
Include member name, AvMed member number, date of birth, prescriber name, date, office contact name, phone and fax number, and DEA or NPI number.
Specify diagnosis (include ICD code if applicable), weight, dosing, and date of service.
Attach supporting documentation to verify prior therapy: chart notes, lab results, diagnostics, and/or pharmacy paid claims.

Denial Risk

Incomplete / Invalid Request

Incomplete, incorrect, or illegible requests — including missing manual signatures — may result in delays or denial of authorization. Ensure all form fields are completed and legible before faxing.

Preprinted or stamped signatures are not valid; signature must be handwritten.
If contact information on the form is incorrect, additional follow-up may be required and processing delayed.

Documentation Required

Insufficient Supporting Documentation

Requests lacking required supporting documentation may be delayed or denied. Verify and attach all evidence of prior therapy and relevant clinical data.

Missing chart notes, lab results, diagnostics, or pharmacy paid claims to verify prior therapy will result in insufficient supporting documentation.
Previous therapies will be verified through pharmacy paid claims or submitted chart notes; use of samples does not satisfy verification.

Definitions and Dosing Guidance

CDC-recommended dosing regimens for pinworm and hookworm treatment (informational)

Pinworm — Pyrantel pamoate11 mg/kg PO once; repeat in 2 weeks

Pinworm — Mebendazole (Emverm)100 mg PO once; repeat in 2 weeks

Pinworm — AlbendazoleChildren >2: 400 mg PO once; repeat in 2 weeks; Children ≤2: 200 mg PO once; repeat in 2 weeks

Hookworm — Pyrantel pamoate11 mg/kg (up to 1 g) PO daily for 3 days

Hookworm — Mebendazole (Emverm)100 mg PO BID for 3 days or 500 mg once

Hookworm — AlbendazoleChildren 3 months to ≤2 years: 200 mg PO once; Children >2 years and adults: 400 mg PO once

Initial Therapy Criteria

CDC dosing guidance

CDC recommended dosing (informational for verification of appropriate prior therapy):

Pinworm dosing examples: Pyrantel pamoate 11 mg/kg base PO once; repeat in 2 weeks; Mebendazole 100 mg PO once; repeat in 2 weeks; Albendazole: for children >2 years 400 mg PO once, repeat in 2 weeks; for children ≤2 years 200 mg PO once, repeat in 2 weeks.

From CDC recommendations on form

Hookworm dosing examples: Pyrantel pamoate 11 mg/kg (up to 1 g) PO daily for 3 days; Mebendazole 100 mg PO BID for 3 days or 500 mg once; Albendazole: for children 3 months to ≤2 years 200 mg PO once; for children >2 years and adults 400 mg PO once.

From CDC recommendations on form

Step Therapy Requirements

Step	Required prior trial (verification)
Pinworm infection	Member must have tried and failed ONE of: at least 2 doses of a pyrantel pamoate product (initial dose and repeat at 2 weeks) OR CDC-recommended dosage of albendazole — verification by chart notes or pharmacy paid claims required.
Hookworm infection	Member must have tried and failed ONE of: at least 3 consecutive daily doses of a pyrantel pamoate product OR CDC-recommended dosage of albendazole — verification by chart notes or pharmacy paid claims required.

Quantity Limits

Emverm (mebendazole) per-fill quantity limit

Emverm (mebendazole) per-fill limit2 tablets per fill

ContextQuantity limits listed in the form under 'Quantity Limits'

Authorization noteIf approved, authorization will be limited to date of service and documentation must be provided for clinical criteria

Albendazole per-fill quantity limit

Albendazole per-fill limit4 tablets per fill

ContextQuantity limits listed in the form under 'Quantity Limits'

VerificationPrior therapy and clinical criteria must be supported by chart notes or pharmacy paid claims to avoid denial

Background

Pinworm and hookworm infections are managed with anthelmintic agents and the policy references CDC‑recommended regimens to verify appropriate prior therapy. For pinworm, typical options include pyrantel pamoate dosing (initial dose with a repeat at 2 weeks) or CDC‑recommended albendazole dosing; for hookworm, options include multi‑day pyrantel pamoate regimens or CDC‑recommended albendazole dosing. These CDC dosing recommendations are provided as informational guidance to confirm whether required prior therapy has been attempted and documented.