CurrentCentenePolicy CP.PMN.269

Ivermectin (Stromectol, Sklice) (PDF)

Defines medical necessity, prior authorization criteria, approvals, denials, dosing and product availability for ivermectin tablets (Stromectol) and ivermectin lotion (Sklice) across Commercial, HIM, and Medicaid lines of business for Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyIvermectin (Stromectol, Sklice) (PDF)

Policy CodePolicy CP.PMN.269

Change TypeStep therapy bypass added (IL HIM)

Effective Date12.01.21

Next Review Date

Key ActionProvider must submit documentation (office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.

SourceLink

POLICY UPDATE CHANGES

For head lice, added step therapy bypass for Illinois HIM per IL HB 5395.

Updated contraindications for Stromectol to align with prescriber information and updated dosing regimen for Sklice.

Policy created and adopted from HIM.PA.124; added criteria for ivermectin tablets.

2Primary Products Covered

14Head lice approval duration (days)

12Tablet approval duration (months)

1Sklice tubes per use allowed

Coverage Summary

Policy Number: CP.PMN.269. Scope: Defines medical necessity, prior authorization criteria, approvals, denials, dosing and product availability for ivermectin tablets (Stromectol) and ivermectin lotion (Sklice) across the following lines of business: Commercial, HIM, Medicaid.

Coverage stance: Covered with criteria. Primary products covered: Stromectol (ivermectin tablets, 3 mg) and Sklice (ivermectin lotion 0.5%, 117 g tube).

High-level approval durations: For head lice treated with Sklice (ivermectin lotion) the approval duration is 14 days (limited to 1 tube per single use). For Stromectol (ivermectin tablets) and other authorized tablet indications the approval duration is 12 months.

Thresholds & Quick Facts

Head lice age threshold≥ 6 months

Sklice max per application1 tube (single use)

Primary products covered2

Head lice approval duration14 days

Tablet approval duration12 months

Initial Therapy Criteria

Initial Approval Criteria

It is medically necessary when the following criteria are met:

A. Head Lice (must meet all)

Request is for ivermectin lotion
Diagnosis of head lice
Age ≥ 6 months≥ 6 months
Failure of permethrin 1% cream, used in the last 60 days, unless contraindicated or clinically significant adverse effects are experiencedlast 60 days

Continuation / Re-authorization Criteria

Re-authorization / Continuation Criteria

Conditions for re-authorization/continuation

A. Head Lice

Re-authorization is not permitted; members must meet the initial approval criteria

B. All Other Indications (must meet all)

Request is for generic ivermectin tablets
Request is not for the prevention or treatment of coronavirus disease 2019 (COVID19)
If request is for a dose increase, new dose does not exceed health plan quantity limit, if applicable

Diagnoses / Indications Not Authorized

Diagnoses/Indications Not Authorized

Coverage is not authorized for the following:

Non-FDA approved indications not addressed in this policy, unless sufficient documentation per off-label use policies or evidence of coverage

Ivermectin tablets for the prevention or treatment of coronavirus disease 2019 (COVID19)

Applicable Codes & Product Availability

Product availability (informational)mixed

N/A	Stromectol: Tablet 3 mg
N/A	Sklice: Lotion 0.5%: 117 g (tube)

Provider Actions & Requirements

Prior Authorization

Prior authorization required

Requests for ivermectin (Stromectol or Sklice) require review against the policy criteria; approval durations differ by indication (14 days for Sklice head lice; 12 months for other indications for tablets).

Documentation Required

Support clinical documentation

Provider must submit documentation (office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.

Clinical Evidence & Guidance

64-100% cure (single 200 mcg/kg dose)Stromectol cure rates for strongyloidiasis per clinical studies

WHO recommends against use for COVID-19 (insufficient evidence)WHO therapeutic guidance on ivermectin for COVID-19 (living guideline)

Evidence summary: Clinical studies cited in the Stromectol prescribing data report cure rates of 64–100% following a single 200 mcg/kg dose for strongyloidiasis. The World Health Organization living guideline recommends against the use of ivermectin tablets for prevention or treatment of COVID-19 due to insufficient evidence regarding benefits and harms.

Alignment and updates: Policy contraindications for Stromectol were updated during the 3Q2024 review to align with prescriber information, and Sklice dosing regimen information was updated at the same time. The 3Q2025 annual review implemented additional administrative changes (e.g., IL HIM step therapy bypass) per the revision log.

Notes for evidence section: This narrative should reference the clinical studies reporting the Stromectol cure rates and the WHO living guideline summarized in the brief, along with the cited prescribing information and updated references listed in the policy.

Background

Background: Ivermectin tablets (Stromectol) are an anthelmintic with FDA indications for the treatment of intestinal strongyloidiasis (Strongyloides stercoralis) and onchocerciasis (Onchocerca volvulus).

Ivermectin lotion (Sklice) is FDA-approved as a topical pediculicide for the treatment of head lice infestations in patients aged ≥ 6 months.

Product/formulation notes: Stromectol is available as 3 mg tablets. Sklice is supplied as 0.5% lotion in a 117 g tube; dosing allows application of up to 1 tube per treatment, and Sklice is specified as a single-use product that should be discarded after use.

Definitions (compact)

FDAFood and Drug Administration

Revision History

09.23.21created

Policy created; adopted from HIM.PA.124 and added criteria for ivermectin tablets. P&T approval 11.21.

05.13.24applied_update

3Q2024 annual review: updated contraindications for Stromectol to align with prescriber information and updated dosing regimen for Sklice; references reviewed and updated. P&T approval 08.24.

04.09.25material_changeLatest

3Q2025 annual review: added step therapy bypass for Illinois HIM per IL HB 5395 for head lice; references reviewed and updated. Revision log notes date 04.09.25 and P&T approval 08.25; effective bypass date for IL HIM is 01.01.2026.

Policy Summary

PayerCentene

PolicyIvermectin (Stromectol, Sklice) (PDF)

Policy CodePolicy CP.PMN.269

Change TypeStep therapy bypass added (IL HIM)

Effective Date12.01.21

Next Review Date

Key ActionProvider must submit documentation (office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.

SourceLink

On This Page

For Illinois HIM requests, the step therapy requirement does not apply as of 2026-01-01 per IL HB 5395

Request does not exceed 1 tube for a single use1 tube

B. All Other Indications (must meet all)

Request is for generic ivermectin tablets
Request is not for the prevention or treatment of coronavirus disease 2019 (COVID19)
Dose does not exceed health plan quantity limit, if applicableplan quantity limit

C. Other diagnoses/indications (must meet 1 or 2)

If this drug has recently (within the last 6 months) undergone a label change not yet reflected in this policy, refer to formulary/no coverage or non-formulary policies as specified (CP.CPA.190, HIM.PA.33 / HIM.PA.103, CP.PMN.255 / CP.PMN.16)6 months
If requested use is NOT specifically listed under section III AND criterion 1 above does not apply, refer to the off-label use policy for the relevant line of business (CP.CPA.09, HIM.PA.154, CP.PMN.53)

C. Other diagnoses/indications (must meet 1 or 2)

If recent label change within last 6 months not reflected here, refer to formulary/no coverage or non-formulary policies (CP.CPA.190, HIM.PA.33 / HIM.PA.103, CP.PMN.255 / CP.PMN.16)6 months
If requested use is NOT listed under section III AND criterion 1 above does not apply, refer to off-label use policy (CP.CPA.09, HIM.PA.154, CP.PMN.53)

Step Therapy

Step therapy for head lice

Failure of permethrin 1% cream used in the last 60 days is required prior to approval of ivermectin lotion unless contraindicated or clinically significant adverse effects; exception/bypass for Illinois HIM per IL HB 5395 effective 2026-01-01.

Billing Rule

Sklice quantity limit

Sklice (ivermectin lotion) approval limited to 1 tube for a single use; product is single-use and should be discarded after use.

Denial Risk

COVID-19 use exclusion

Requests for ivermectin tablets for prevention or treatment of COVID-19 are not authorized and will be denied.