CurrentNeighborhood Health Plan of Rhode IslandPolicy 4831-D

Ovide (malathion) — coverage and prior authorization criteria for head lice

Defines prior authorization and step therapy requirements for coverage of Ovide (malathion) for treatment of Pediculus humanus capitis (head lice) under the payer's prescription benefit; affects prescribers and pharmacy claims adjudication.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOvide (malathion) — coverage and prior authorization criteria for head lice

Policy CodePolicy 4831-D

Change TypeNo material change

Effective DateMar 20, 2023

Next Review Date

Key ActionObtain prior authorization when the patient has not met initial step therapy (no permethrin 1% fill within the past 60 days) or when coverage criteria require PA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1FDA-approved indication listed

60Permethrin lookback (days)

permethrin 1%First-line referenced

Coverage Criteria

COVERAGE CRITERIA

Covered with prior authorization when ALL of the following are met:

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Main requirements

Permethrin failure/intolerance/contraindication/resistance: At least one of: inadequate treatment response to permethrin 1%; intolerance to permethrin 1%; contraindication to permethrin 1%; OR local pattern of known or suspected resistance to permethrin 1%

Operational note: Prior authorization is required when the patient has not met the initial step therapy (no documented permethrin 1% use within the past 60 days) or when the above criteria are otherwise not satisfied.

See step therapy and prior authorization rules for documentation requirements

No explicit additional exclusions are listed in this policy beyond the requirement that the requested drug be prescribed for treatment of Pediculus humanus capitis (head lice and their ova) of the scalp hair. Coverage is governed by the criteria in this policy and any request must meet those conditions to be considered for prior authorization.

Use of Ovide (malathion) when the patient has not met the initial step therapy requirement will be rejected at claim adjudication and will require a prior authorization for evaluation. The initial step therapy requires that the patient has filled at least a 1‑day supply of permethrin within the past 60 days under the administered prescription benefit; if that lookback is not met the claim will reject with a message that a prior authorization is required.

Coding and Lookback

Permethrin lookback

Lookback periodPatient has filled ≥1 day supply of permethrin within the past 60 days under the prescription benefit

ScopeIncludes prescription permethrin fills administered by the payer's prescription benefit (CVS Caremark referenced in source)

Consequence if unmetIf no qualifying permethrin fill is found in the prior 60 days, the claim will reject and require prior authorization

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required When Step Therapy Not Met

Prior authorization is required for Ovide when the patient has not met initial step therapy (a recent permethrin 1% fill within 60 days). Claims will reject if the patient does not meet the initial step therapy criteria and will require prior authorization for evaluation.

If the patient has filled at least a 1-day supply of permethrin 1% (prescription) within the past 60 days under the administered prescription benefit, step therapy is satisfied.
If the patient does not meet the initial step therapy criteria, the claim will reject with a message that a prior authorization (PA) is required. PA criteria will be applied to requests submitted to the PA unit.

Step Therapy

Initial Step Therapy with Permethrin 1%

If the patient has filled at least a 1-day supply of permethrin 1% (prescription) within the past 60 days under the administered prescription benefit (including Rx and OTC products when stated), the initial step therapy requirement is satisfied and no PA for Ovide based on step therapy is needed.

Includes prescription and OTC products unless otherwise stated.
Window: within the past 60 days.
Administered under the prescription benefit managed by CVS Caremark.

Documentation Required

Required Supporting Information

Documentation should support the diagnosis of Pediculus humanus capitis (head lice and ova) and include evidence of inadequate response, intolerance, contraindication to permethrin 1%, or other clinical rationale (for example, local permethrin resistance) to justify use of Ovide when step therapy is not met.

Diagnosis: Pediculus humanus capitis.
Supporting evidence: prior treatment failure or intolerance to permethrin 1%, contraindication to permethrin 1%, or documentation of local/perceived resistance to permethrin 1%.

Denial Risk

Claim Rejection if Step Therapy Unmet

Claims will be denied/rejected when initial step therapy is unmet; submit a prior authorization request for evaluation to the PA unit to determine if an exception applies.

Claim rejection message indicates PA is required when no qualifying permethrin 1% fill in the past 60 days is found.
Submit PA with supporting documentation as described above for consideration.

Background

Ovide (malathion) is FDA‑approved for treatment of Pediculus humanus capitis (head lice and their ova) of the scalp hair. This policy treats Ovide as a non–first‑line agent that is eligible for coverage only when the coverage criteria are satisfied, typically after failure, intolerance, contraindication, or local resistance to first‑line therapy with permethrin 1% and when prior authorization requirements are met.

Definitions / Indication

Indication

IndicationTreatment of Pediculus humanus capitis (head lice and their ova) of the scalp hair.

Coverage requirementRequested drug must be prescribed for Pediculus humanus capitis to be considered under these criteria

Supporting documentationDocumentation should support diagnosis and, when applicable, inadequate response, intolerance, contraindication, or local resistance to permethrin 1%