CurrentAvMedPolicy N/A

Ivermectin (Stromectol) prior authorization and step-edit coverage criteria

Form and criteria governing prior authorization and step-edit requests for oral ivermectin (Stromectol) for AvMed members; applies to prescribers requesting coverage via pharmacy benefit.

Policy Summary

PayerAvMed

PolicyIvermectin (Stromectol) prior authorization and step-edit coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must sign and fax the completed prior authorization form with all supporting documentation to 1-305-671-0200.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20quantity limit per 90 days

2FDA-approved indications listed

1required prescriber signature

Coverage Criteria

Approval criteria

All criteria must be met for approval; to support each checked line, documentation must be provided.

Approval criteria: Member must have a diagnosis of one of the following FDA-approved indications: onchocerciasis OR strongyloidiasis; all supporting documentation (lab results, diagnostics, chart notes) must be provided for each checked criterion; prescriber must complete and sign the authorization form

Use of samples to initiate therapy does not meet step edit/preauthorization criteria; previous therapies will be verified via pharmacy paid claims or submitted chart notes

Use of samples to initiate therapy does not meet step edit/preauthorization criteria. This policy requires verification of prior therapies through pharmacy paid claims or submitted chart notes; initiation with drug samples alone will not satisfy the step-therapy requirement and may result in denial of the request.

Coding

Diagnosis codes (member-supplied)ICD-10

ICD Code, if applicable (field present on form)

Policy Summary

PayerAvMed

PolicyIvermectin (Stromectol) prior authorization and step-edit coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must sign and fax the completed prior authorization form with all supporting documentation to 1-305-671-0200.

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.

Quantity limit — inv-04

Quantity limit20 tablets per 90 days

Per time periodper 90 days

Unittablets

Provider Actions & Requirements

Prior Authorization

Authorization submission

Prior authorization requests must be signed by the prescribing physician (preprinted stamps are not valid) and faxed to 1-305-671-0200. All required form fields — including member identifiers, prescriber contact, DEA or NPI, and clear dosing/diagnosis information — must be completed. Incomplete, incorrect, or illegible requests or missing contact information may delay processing.

Fax completed and signed form to 1-305-671-0200
Include Member AvMed #, member name, DOB, prescriber name, prescriber signature, date, office contact, phone and fax numbers, and DEA or NPI
Ensure drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight, date, and quantity requested are provided

Step Therapy

Step-edit / sample policy

Use of drug samples to start therapy does not satisfy step-edit or preauthorization criteria. The payer will verify prior therapies via pharmacy paid claims or submitted chart notes.

Samples used to initiate therapy do not meet step edit/preauthorization requirements
Previous therapies will be verified through pharmacy paid claims or chart documentation

Documentation Required

Required supporting documentation

Provide documentation to support each checked clinical criterion. Required supporting documentation includes lab results, diagnostic reports, and chart notes; absence of these documents may result in denial or delay.

Attach lab results, diagnostic reports, and relevant chart notes for each criterion checked
All clinical criteria listed on the form must be met and supported for approval

Documentation Required

Form completion requirements

The prescriber must sign and clearly print their name on the request (preprinted stamps are not valid). Include member identifiers and prescriber contact details to avoid delays.

Prescriber signature and printed name required
Include Member AvMed #, Member name, DOB, office contact, phone, fax, and DEA or NPI

Denial Risk

Incomplete or insufficient documentation

Authorization may be delayed or denied if the request is incomplete, incorrect, illegible, or lacking required supporting documentation (labs, diagnostics, chart notes). Quantity limits and indication requirements will be enforced.

Incomplete/illegible forms may delay processing
Missing supporting documentation can result in denial
Quantity limit: 20 tablets per 90 days
Member must have a diagnosis of an FDA‑approved indication (Onchocerciasis or Strongyloidiasis) — all criteria must be met

Background

Ivermectin (Stromectol) is an antiparasitic agent listed on the prior authorization form for treatment of FDA‑approved indications. The form requires the prescriber to document the member’s diagnosis (for example, onchocerciasis or strongyloidiasis) and to supply supporting clinical evidence including lab results, diagnostics, and chart notes as applicable. Requests that are incomplete or lack required documentation may be delayed or denied.

Definitions

FDA-approved indications — inv-11

FDA‑approved indications (qualifying diagnoses)Onchocerciasis; Strongyloidiasis

Form requirementMember must have a diagnosis of one of the listed FDA‑approved indications

DocumentationSupporting documentation (labs, diagnostics, chart notes) must be provided for each checked criterion

Initial Therapy Criteria

Initial approval requires diagnosis and supporting documentation.

Initial therapy: Member must have a diagnosis of onchocerciasis OR strongyloidiasis; prescriber-signed authorization form and supporting documentation (labs, diagnostics, chart notes) must be provided; quantity limited to 20 tablets per 90 days20 tablets per 90 days

Samples do not satisfy initiation; previous therapies will be verified via pharmacy paid claims or submitted chart notes

Step Therapy

Step	Requirement
1	Previous therapies will be verified through pharmacy paid claims or submitted chart notes; samples do not meet step-edit/preauthorization criteria.

Quantity Limits

ivermectin (Stromectol) tablets — inv-14

Drugivermectin (Stromectol) tablets

Quantity limit (see quantity limits)20 tablets per 90 days

IndicationsOnchocerciasis; Strongyloidiasis