Benzimidazole Antihelminths (albendazole/Albenza)
Customize your policy alerts
Sign up for all careoregon policy alerts
Know when careoregon releases new policies or updates existing guidance.
Monitor payer policy activity
Policy governing prior authorization and medical necessity criteria for benzimidazole antihelminth medication (including albendazole/Albenza) for treatment of helminth infections; applies to CareOregon members and prescribers requesting coverage.
No material clinical or coverage changes in this revision.
Coverage Criteria
This policy applies an algorithmic coverage approach based on the member's diagnosis and prior therapy. For requests routed through the non-pinworm pathway, albendazole/Albenza will only be considered when the prescriber is an infectious disease specialist and the requested use is for a supported indication at an appropriate dose and duration. If the prescriber specialty requirement is not met, the request is excluded and will not be approved.
Albendazole is not approved when policy step-therapy requirements are unmet. Specifically, for pinworm (Enterobius vermicularis) cases, authorization requires documented failure of two doses of pyrantel (Pin-X/Reese's Pinworm) given 2 weeks apart; requests that do not show this are not approved. For non-pinworm indications, requests are not approved if the prescriber is not an infectious disease specialist, or if the indication, dose, or duration are not consistent with supported use.
Coding
| No codes listed |
Provider Actions and Requirements
Prior authorization — show stepwise criteria met
Prior authorization requires submission of evidence that the stepwise criteria have been met: for pinworm, documentation that the member has tried and failed two doses of pyrantel (Pin-X/Reese's Pinworm) dosed 2 weeks apart; for non-pinworm indications, the prescriber must be an infectious disease specialist and the use must be for a supported indication at an appropriate dose and duration.
- Pinworm pathway: failure of two pyrantel doses given 2 weeks apart is required.
- Non-pinworm pathway: prescriber must be an infectious disease specialist and indication/dose/duration must be supported.
Step therapy for pinworm — two pyrantel doses required
Step therapy requires a trial and documented failure of two doses of pyrantel (Pin-X/Reese's Pinworm) administered 2 weeks apart before albendazole will be approved for pinworm.
- Two doses of pyrantel separated by 2 weeks must have been tried and failed.
- If the two-dose pyrantel trial is met, approve albendazole for 1 day per policy flow.
Required documentation — show pyrantel trials and prescriber specialty
Required documentation must demonstrate prior use and failure of two pyrantel doses (Pin-X/Reese's Pinworm) given 2 weeks apart for pinworm cases; for non-pinworm requests, document prescriber specialty (infectious disease) and that the indication, dose, and duration are supported.
- Evidence of two pyrantel doses administered 2 weeks apart and objective or clinical documentation of failure.
- For other indications, include prescriber specialty and indication with dose and duration consistent with supported use.
Reasons for denial — missing pyrantel failures or specialty/indication issues
Requests will be denied if step therapy is not met for pinworm (i.e., the patient has not failed two pyrantel doses given 2 weeks apart); other denial reasons include prescriber not being an infectious disease specialist for non-pinworm indications, or use that is not for a supported indication or appropriate dose/duration.
- Do not approve if pinworm patient has not tried and failed two pyrantel doses 2 weeks apart.
- Do not approve if prescriber is not an infectious disease specialist for non-pinworm pathways.
- Do not approve if indication, dose, or duration are not supported by the policy.
Background
Albendazole is a benzimidazole antihelminth included in this policy (product example: Albenza (albendazole)) for treatment of helminth infections such as pinworm and other supported indications. The policy implements step-therapy and specialty-prescriber checks to promote appropriate use and requires documentation of prior pyrantel therapy for pinworm or specialist prescriber status and appropriate dosing for other indications.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.