Cigna Antiparasitics Quantity Limits Policy Update

Coverage Criteria and Drug-Specific Rules

Drug-specific dosing and indication references

Drug-specific indications and dosing (FDA and selected CDC/advisory guidance) as provided in the policy:

Albendazole: Indicated for hydatid disease (Echinococcus granulosus) and neurocysticercosis (Taenia solium); dosing is weight-based with specific cycle/duration guidance (hydatid disease: 400 mg BID or 15 mg/kg/day in divided doses for <60 kg with 28-day cycles and 14-day drug-free intervals for 3 cycles; neurocysticercosis: 400 mg BID or 15 mg/kg/day for 8–30 days). CDC also recommends albendazole for Baylisascaris (25–50 mg/kg/day for 10–20 days) and as an alternative for clonorchiasis (10 mg/kg/day for 7 days).see Table 2

Chunk 9 provides dosing tables and CDC notes.

Nitazoxanide (Alinia): Indicated for diarrhea due to Giardia lamblia and Cryptosporidium parvum; suspension for ≥1 year and tablets for ≥12 years. Routine duration is 3 days (500 mg Q12H adults); CDC/IDSA/HIV guidance supports extended dosing (500–1000 mg BID for 14 days) for cryptosporidiosis in immunocompromised patients.500 mg Q12H x3 days (adults); suspension dosing by age

Chunk 10.

Arakoda (tafenoquine): Approved for malaria prophylaxis with recommended loading (200 mg QD x3 days), maintenance (200 mg QW), and terminal dosing (single 200 mg dose 7 days after last maintenance); may be administered for up to 6 months continuous dosing.loading 200 mg QD x3 days; maintenance 200 mg QW

Chunk 11.

Benznidazole: Used for Chagas disease in pediatric patients (2–12 years): weight-based dosing 5–8 mg/kg/day divided BID for 60 days; CDC recognizes adult dosing (5–7 mg/kg/day divided BID for 60 days) in some circumstances.5–8 mg/kg/day divided BID x60 days

Chunk 12.

Coartem (artemether/lumefantrine): 3-day treatment schedule (six doses total) with total tablets dependent on weight (adult course typically 24 tablets for ≥35 kg; pediatric weight-based tablet totals provided).weight-based 3-day regimen; see chunk 14 for per-weight totals

Chunk 14.

Emverm (mebendazole): Dose varies by indication: single dose for pinworm (1 tablet one time); for whipworm/roundworm/hookworm 1 tablet BID x3 days. CDC guidance provides off-label regimens for capillariasis, trichinellosis, and toxocariasis with specified doses/durations.pinworm: 1 tablet single dose; others: 1 tablet BID x3 days; CDC off-label regimens noted

Chunk 15.

Impavido (miltefosine): Weight-based dosing with a 28-day duration: 50 mg BID for patients 30–44 kg; 50 mg TID for patients ≥45 kg.50 mg BID (30–44 kg) or 50 mg TID (≥45 kg) x28 days

Chunk 16.

Krintafel (tafenoquine): Single 300 mg dose (two 150-mg tablets) for radical cure of P. vivax; tablets cannot be broken/crushed/chewed; if vomiting occurs within 1 hour, a single repeat dose may be given (re-dosing not to exceed once).300 mg single dose

Chunk 17.

Lampit (nifurtimox): Weight-based dosing for pediatric Chagas disease with TID dosing for 60 days; tablet strengths (30 mg, 120 mg) and splitting guidance provided with detailed per-weight dosing tables for patients <18 years.TID x60 days; weight-based mg/kg dosing per Tables 6-7

Chunks 18-19.

Albendazole special approval criteria

Covered as medically necessary when the listed Drug Quantity Management criteria are met; exceptions considered not medically necessary unless criteria below are met.

Albendazole - Baylisascariasis: If the request is for the treatment of Baylisascariasis, approve a one-time override for a quantity sufficient to accommodate a dose of up to 50 mg/kg/day for up to 20 days at retail or home delivery.up to 50 mg/kg/day for up to 20 days

Round up to nearest whole tablet when calculating quantity; example provided (70 kg => 360 tablets).

Albendazole - Clonorchiasis: If the request is for the treatment of Clonorchiasis, approve a one-time override for a quantity sufficient to accommodate a dose of up to 10 mg/kg/day for 7 days at retail or home delivery.up to 10 mg/kg/day for 7 days

Drug quantity limits

Drug-specific quantity limits (retail and home delivery). Approvals are provided when requests are within these maximum quantities; exceptions handled per criteria above or general override process.

Quantity limits list: Each product has a specified maximum quantity per time period and dispensing channel (examples include Albendazole 200 mg: retail max 120 per 30 days; home delivery max 360 per 90 days; Lampit 30 mg retail max 720 per 180 days (max 360 per dispensing); Malarone pediatric retail max 180 per 180 days; ivermectin 6 mg retail max 8 per 30 days; ivermectin 6 mg home delivery max 24 per 90 days).see product-specific entries in document

Full list present in document (chunks 34–36).

Albendazole overrides

Albendazole 200 mg tablets: overrides when ALL of the following apply for each indication

Albendazole overrides: Approve a one-time override for quantity sufficient to accommodate: up to 50 mg/kg/day for up to 20 days for Baylisascariasis OR up to 10 mg/kg/day for 7 days for Clonorchiasis; round up to nearest whole tablet per dose when calculating quantity.50 mg/kg/day (Baylisascariasis); 10 mg/kg/day for 7 days (Clonorchiasis)

Example calculation provided (70 kg => 360 tablets).

Nitazoxanide overrides

Nitazoxanide (Alinia) tablets and suspension: overrides when ALL of the following apply

Cryptosporidiosis in immunocompromised patients: If treating Cryptosporidiosis in an immunocompromised patient (e.g., transplant, HIV), approve a one-time override for the requested quantity not to exceed 56 tablets (500 mg tablets) or 1,400 mL suspension.<=56 tablets; <=1400 mL

Applies to both 500 mg tablets and 100 mg/5 mL suspension.

Malaria prophylaxis overrides

Malaria prophylaxis products: per-days overrides for extended prophylaxis (>60 days)

Arakoda per days: If the patient needs prophylaxis for malaria for > 60 days, approve a one-time override sufficient to allow: 2 tablets daily for 3 days prior to travel (6 tablets), 2 tablets weekly during the stay (2/week), and 2 tablets one time 7 days after return (2 tablets).>60 days

Retail or home delivery.

Atovaquone/proguanil pediatric: If the patient weighs ≤ 40 kg and needs prophylaxis for > 60 days, approve a one-time override sufficient for: up to 3 tablets daily for 2 days before travel (6 tablets), up to 3 tablets daily during stay (3/day), and 3 tablets daily for 7 days after return (21 tablets). Also approve up to 3 additional tablets for a repeat dose after vomiting.<=40 kg; >60 days

Retail or home delivery.

Atovaquone/proguanil adult: If the patient weighs > 40 kg and needs prophylaxis for > 60 days, approve a one-time override sufficient for: 1 tablet daily for 2 days before travel (2 tablets), 1 tablet daily during stay (1/day), and 1 tablet daily for 7 days after return (7 tablets). Also approve up to 4 additional tablets for a repeat dose after vomiting.

Chagas disease overrides

Benznidazole and Lampit (nifurtimox) for Chagas disease: overrides when ALL apply

Benznidazole 12.5 mg per days: If the patient is diagnosed with a new episode of Chagas disease since the last 60-day treatment with benznidazole, approve a one-time override for the requested quantity, not to exceed 720 tablets.<=720 tablets

Retail or home delivery.

Benznidazole 100 mg weight-based: If the patient weighs >150 kg, approve a one-time override sufficient to accommodate a dose up to 8 mg/kg/day for 60 days; round up tablets per dose (example: 170 kg => 840 tablets).>150 kg; 8 mg/kg/day for 60 days

Retail or home delivery.

Lampit overrides: If the patient is diagnosed with a new episode of Chagas disease since the last 60-day treatment with Lampit, approve a one-time override for the requested quantity not to exceed 720 tablets (30 mg strength) or 540 tablets (120 mg strength) as applicable.

Emverm overrides

Emverm (levamisole) specific indications

Capillariasis: Approve a one-time override of 80 tablets for Capillariasis.80 tablets

Retail or home delivery.

Trichinellosis: Approve a one-time override for the requested quantity, not to exceed 186 tablets for Trichinellosis.<=186 tablets

Retail or home delivery.

Toxocariasis/Visceral Larva Migrans: Approve a one-time override of 20 tablets for Toxocariasis or Visceral Larva Migrans.20 tablets

Retail or home delivery.

Krintafel repeat dose override

Krintafel (tafenoquine) repeat dose allowance

Repeat dose after vomiting: If the request is for a repeat dose in a patient who has vomited, approve a one-time override for 2 additional tablets.2 tablets

Retail or home delivery.

Atovaquone/proguanil (pediatric) Overrides

Atovaquone/proguanil pediatric 62.5 mg/25 mg tablets (Malarone, generic) - covered with one-time override when ALL of the following apply

Atovaquone/proguanil pediatric override for >60 days prophylaxis: If the patient weighs ≤ 40 kg AND needs prophylaxis for malaria for > 60 days, approve a one-time override sufficient for: up to 3 tablets daily for 2 days before travel (6 tablets), up to 3 tablets daily during the stay (3/day), and 3 tablets daily for 7 days after return (21 tablets).<=40 kg; >60 days

Applies to retail or home delivery

Atovaquone/proguanil pediatric repeat dose after vomiting: If the request is for a repeat dose in a patient who has vomited, approve a one-time override of up to 3 additional tablets.repeat dose after vomiting

Retail or home delivery

Atovaquone/proguanil (adult) Overrides

Atovaquone/proguanil 250 mg/100 mg tablets (Malarone, generic) - covered with one-time override when ALL of the following apply

Atovaquone/proguanil adult override for >60 days prophylaxis: If the patient weighs > 40 kg AND needs prophylaxis for malaria for > 60 days, approve a one-time override sufficient for: 1 tablet daily for 2 days before travel (2 tablets), 1 tablet daily during the stay (1/day), and 1 tablet daily for 7 days after return (7 tablets).>40 kg; >60 days

Retail or home delivery

Atovaquone/proguanil adult repeat dose after vomiting: If the request is for a repeat dose in a patient who has vomited, approve a one-time override up to 4 additional tablets.repeat dose after vomiting

Retail or home delivery

Mefloquine Overrides

Mefloquine 250 mg tablets - covered with one-time override when ALL of the following apply

Mefloquine prophylaxis >60 days: If the patient needs prophylaxis for malaria for > 60 days, approve a one-time override sufficient to allow: 1 tablet weekly for 4 weeks before travel (4 tablets), 1 tablet weekly during the stay (1/week), and 1 tablet weekly for 4 weeks after return (4 tablets).>60 days

Retail or home delivery

Mefloquine repeat dose after vomiting: If the request is for a repeat dose in a patient who has vomited, approve a one-time override of up to 5 additional tablets.repeat dose after vomiting

Retail or home delivery

Primaquine Overrides

Primaquine phosphate 26.3 mg tablets - covered with one-time override when ALL of the following apply

Primaquine prophylaxis >60 days: If the patient needs prophylaxis for malaria for > 60 days, approve a one-time override sufficient to allow: up to 2 tablets daily for 2 days before travel (4 tablets), 2 tablets daily during the stay (2/day), and 2 tablets daily for 7 days after return (14 tablets).>60 days

Retail or home delivery

Ivermectin Overrides and Indications

Ivermectin (3 mg and 6 mg) - covered with one-time override when ANY of the following specific treatment indications are met

Trichuriasis (Trichuris trichiura): Approve a one-time override for a quantity sufficient to provide ivermectin 200 mcg/kg/day for 3 days; round up tablets per dose.200 mcg/kg/day x 3 days

Examples provided; retail or home delivery

Pediculosis (lice): Approve a one-time override for quantity sufficient to provide up to 400 mcg/kg/day (single dose) for two doses; round up tablets per dose.up to 400 mcg/kg (1 dose) x 2

Examples provided; retail or home delivery

Scabies treatment: Approve a one-time override for quantity sufficient to provide ivermectin 200 mcg/kg/dose for up to 7 doses; round up tablets per dose.

This coverage policy applies to health benefit plans administered by Cigna companies. Certain Cigna companies and/or lines of business only provide utilization review services and do not make coverage determinations; references to standard benefit plan language may not apply to those clients. Coverage determinations are ultimately governed by the member’s specific benefit plan document and applicable law.

If a request does not meet the Drug Quantity Management rule for the requested product at the point of service, coverage will be determined by the criteria in this policy. Any request that fails to meet the Drug Quantity Management criteria listed (including the product-specific maximum quantities by dispensing channel) is considered not medically necessary unless an applicable override criterion is met. Note that 'one-time' approvals are provided for 30 days in duration.

Any request that does not meet the specific one-time override criteria provided for the product in this policy is considered not medically necessary. Requests exceeding the listed maximum quantities per product and supply period will be denied unless an approved one-time override criterion applies.

For quinine sulfate 324 mg capsules (Qualaquin, generic), the policy specifies that no overrides are recommended. Requests for quantity overrides for this product are not supported and are likely to be denied.

Any other exception beyond the specified drug quantity management criteria and listed one-time override conditions is considered not medically necessary. Providers should reference the product-specific criteria and allowable override indications before submitting requests for quantities that exceed standard limits.

Exceptions that fall outside the listed override indications, allowable quantities, or dispensing-channel limits (retail vs home delivery) are considered not medically necessary. The policy’s product-specific sections define the limited circumstances in which one-time overrides may be approved.

Quantity override requests for quinine sulfate 324 mg capsules (Qualaquin, generic) are not supported by this policy. The policy explicitly states no overrides recommended for this product; therefore requests to exceed the listed maximum quantities should be expected to be denied.

Product Codes, Identifiers, and Quantity Limits

Product listing (no codes provided)NDC

NDC(s) not listed

Document lists product names and strengths but does not provide NDC codes in this segment.

Referenced drug identifiers and prescribing informationmixed

NDC	Various product NDCs referenced indirectly via prescribing information (not enumerated in this section)

inv-24: Weight-based dosing example — rounding and calculations

Rounding ruleRound up to the nearest whole tablet per dose when calculating weight-based quantities.

Albendazole example — patient weight70 kg

Albendazole example — daily dose calculation70 kg × 50 mg/kg/day = 3,500 mg/day divided BID ≈ 1,700 mg per dose; round up to nearest tablet: 18 tablets/day

Albendazole example — total quantity18 tablets/day × 20 days = 360 tablets total

Benznidazole example — patient weight170 kg

Benznidazole example — total quantity170 kg × 8 mg/kg/day = 1,360 mg/day divided BID ≈ 680 mg per dose → round up to tablets: 14 tablets/day × 60 days = 840 tablets total

Provider Actions, Prior Authorization, and Billing Guidance

Note

Applicability and Prior Review Note

This coverage policy applies to health benefit plans administered by Cigna companies. Certain Cigna entities or lines of business provide utilization review only and do not make coverage determinations; standard benefit plan language may not apply to those clients. Where a client-specific benefit plan document conflicts with this policy, the client document controls. Coverage determinations require consideration of the applicable benefit plan document, applicable laws/regulations, relevant collateral materials, and the facts of the case. Claims submitted without covered diagnosis/procedure codes or that do not meet the Drug Quantity Management rule at the point of service may be denied. One-time approvals are provided for 30 days in duration.

Applies to Cigna-administered health benefit plans; some Cigna entities provide utilization review only and do not make coverage determinations.
In event of conflict, the customer's benefit plan document supersedes this policy.
Coverage requests reviewed on individual merits; claims missing covered codes will be denied.
If Drug Quantity Management rule is not met at point of service, coverage is determined by the criteria; one-time approvals = 30 days.

Prior Authorization

Background, Definitions, and Dosing Notes

Antiparasitic agents are used to treat a variety of parasitic infections; appropriate drug selection, dose, and duration depend on the infecting parasite and the clinical scenario. This policy provides drug-specific dosing references and defines per-prescription and per-days quantity limits, with limited one-time overrides for specific clinical indications to promote safe, effective, and economical use of these medications.

inv-44: Antiparasitic agents indications

AlbendazoleHydatid disease; Neurocysticercosis

Nitazoxanide (Alinia)Diarrhea due to Giardia lamblia and Cryptosporidium parvum

Arakoda (tafenoquine)Malaria prophylaxis

BenznidazoleChagas disease (American trypanosomiasis) in patients 2–12 years

Emverm (mebendazole)Gastrointestinal infections: pinworm, whipworm, roundworm, hookworm

OpenPayer

Infectious Disease - Antiparasitics Drug Quantity Management Policy - Per Rx and Per Days

Coverage Criteria and Drug-Specific Rules

Product Codes, Identifiers, and Quantity Limits

Provider Actions, Prior Authorization, and Billing Guidance

Background, Definitions, and Dosing Notes