CurrentAvMedPolicy N/A

Nitazoxanide (Alinia)

Prior authorization form and clinical criteria for coverage of nitazoxanide (Alinia) including required prescriber qualifications, diagnoses, documentation, and quantity/age limits. Applies to pharmacy benefit requests submitted to AvMed.

Policy Summary

PayerAvMed

PolicyNitazoxanide (Alinia)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescribing physician must sign and clearly print name on the request form; submit form by fax to 1-305-671-0200 with complete member, prescriber, drug, dosing, diagnosis, weight, and date information.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

2Covered Indications

1Approval per lifetime

2Required documentation items

Coverage Summary

Prior authorization is required for nitazoxanide (Alinia) and is limited to confirmed infections with Giardia lamblia or Cryptosporidium parvum. Approval requires that the prescriber be a gastroenterologist or infectious disease specialist and that lab test results confirming the diagnosis be submitted. Age and quantity limits apply: children 1–11 years: maximum 60 mL (1 bottle); children and adults ≥12 years: maximum 6 tablets; and a maximum of 1 approval per lifetime.

Age-based quantity limits

Age-based quantity limits (Children 1-11 years)Maximum approval of 60 mL (1 bottle)

Age-based quantity limits (Children and adults >=12 years)Maximum approval of 6 tablets

Limit per lifetimeMaximum of 1 approval per lifetime

Clinical Criteria for Approval

Policy Summary

PayerAvMed

PolicyNitazoxanide (Alinia)

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

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Provider Actions & Prior Authorization

Prior Authorization

Prior authorization submission

Prescribing physician must sign and clearly print name on the prior authorization request form (preprinted stamps are not valid). Fax the completed form to 1-305-671-0200. Include complete member, prescriber, drug, dosing, length of therapy, diagnosis (with ICD code if applicable), weight, dates, and contact phone/fax information.

Fax number: 1-305-671-0200
Required form fields: Member name, Member AvMed #, Date of birth
Required form fields: Prescriber name, Prescriber signature (signed and printed), DEA or NPI
Required form fields: Office contact name, Phone number, Fax number
Required form fields: Drug form/strength, Dosing schedule, Length of therapy
Required form fields: Diagnosis and ICD code (if applicable), Weight, Date

Documentation Required

Support clinical criteria with documentation

Support each checked clinical criterion with documentation. Submit laboratory test results that confirm Giardia lamblia or Cryptosporidium parvum infection, plus any relevant chart notes or evidence of prior therapies. Incomplete, incorrect, or illegible information may delay processing or lead to denial.

Lab test results confirming Giardia lamblia or Cryptosporidium parvum
Chart notes or prior therapy evidence (previous therapies may be verified through pharmacy paid claims or submitted chart notes)
Ensure all submitted documentation is complete, correct, and legible to avoid delays or denial

Documentation Required

Prescriber specialty requirement

Per the approval criteria, the prescribing clinician must be a gastroenterologist or an infectious disease specialist. Confirm and document the prescriber specialty on the request form.

Prescriber must be a gastroenterologist or infectious disease specialist (document on form)

Billing Rule

Sample use not acceptable for PA

Use of medication samples to start therapy does not meet the plan's step edit or preauthorization requirements and will not satisfy PA criteria.

Samples do not satisfy step edit/preauthorization criteria

The prescribing physician must sign and clearly print their name on the request form; preprinted stamps are not valid. Place the prescriber signature and date in the designated signature and date fields on the form (Prescriber Signature / Date).

Background

This form and accompanying clinical criteria establish the pharmacy prior authorization process for nitazoxanide (Alinia). The scope of approval is limited to confirmed infections due to Giardia lamblia or Cryptosporidium parvum, requires a specialist prescriber (gastroenterologist or infectious disease specialist), and mandates submission of laboratory confirmation to support the request. These requirements apply to AvMed pharmacy benefit prior authorization requests.

The form collects member, prescriber, drug, dosing, diagnosis, and supporting documentation details and notes that incomplete, incorrect, or illegible information may delay or result in denial of the authorization.

OpenPayer

Nitazoxanide (Alinia)

Coverage Summary

Clinical Criteria for Approval

Provider Actions & Prior Authorization

Applicable Codes

Background

Clinical Evidence

Revision History