CurrentNeighborhood Health Plan of Rhode IslandPolicy 4831-D

Ovide (malathion) coverage — prior authorization and step therapy

This policy governs coverage and prior authorization requirements for Ovide (malathion) lotion for treatment of head lice (Pediculus humanus capitis) for members under the payer's pharmacy benefit, including step therapy rules that reference prior use of permethrin 1%. It affects prescribers and pharmacists submitting claims and PA requests.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOvide (malathion) coverage — prior authorization and step therapy

Policy CodePolicy 4831-D

Change TypeNo material change

Effective DateMar 1, 2023

Next Review Date

Key ActionObtain prior authorization when there is no documented permethrin 1% fill within the past 60 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

permethrin 1%required initial step therapy agent referenced

head liceindication (Pediculus humanus capitis)

prior authorizationcoverage requires PA when step not met

Coverage Criteria for Ovide (malathion)

PA coverage criteria for Ovide

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Indication: The requested drug is being prescribed for the treatment of Pediculus humanus capitis (head lice and their ova) of the scalp hair

Permethrin-related prerequisites: One of: the patient has experienced an inadequate treatment response to permethrin 1%; the patient has experienced an intolerance to permethrin 1%; the patient has a contraindication that would prohibit a trial of permethrin 1%; there is a local pattern of known or suspected resistance to permethrin 1%

These are alternatives (OR) that satisfy the step-therapy exception for prior authorization approval.

Requests where the initial step therapy requirement is met — defined as the patient having filled at least a 1 day supply of permethrin 1% within the past 60 days under the prescription benefit administered by CVS Caremark — will be adjudicated under that prescription benefit rather than paid as Ovide without further prior authorization. If the initial step therapy criterion is satisfied, the requested drug will be paid under the permethrin prescription benefit.

If the patient does not meet the initial step therapy requirement, the claim will reject with a message indicating that a prior authorization (PA) is required and the PA criteria for Ovide will be applied.

Provider Actions, Prior Authorization, and Step Therapy

Prior Authorization

Prior Authorization Required

Prior Authorization Required when initial step not met. PA is required when documentation does not show the patient filled at least a 1 day supply of permethrin 1% within the past 60 days under the prescription benefit administered by CVS Caremark.

Claims will reject and require prior authorization if the patient has not filled at least a 1 day supply of permethrin 1% within the past 60 days.
If initial step therapy is satisfied (see 'Initial Step Therapy with permethrin 1%'), the requested drug will be paid under the prescription benefit; otherwise submit a PA request for evaluation.

Step Therapy

Initial Step Therapy with permethrin 1%

Initial step therapy is met when the patient has filled a prescription for at least a 1 day supply of permethrin 1% within the past 60 days under a prescription benefit administered by CVS Caremark. Rx and OTC products are included unless otherwise stated. If this step is satisfied, the requested drug will be paid under the prescription benefit rather than through a PA.

Requires pharmacy claim evidence of a permethrin 1% fill covering >=1 day within the prior 60 days.
If no such fill is documented, the claim will reject with a message that prior authorization is required.

Documentation Required

Required documentation for PA

Required documentation for prior authorization. PA requests must document the diagnosis and why permethrin 1% is not appropriate or was ineffective.

Documented diagnosis of Pediculus humanus capitis (head lice and/or ova) of the scalp hair.
Evidence of inadequate response to permethrin 1% (clinical notes, treatment dates, outcomes) OR documented intolerance to permethrin 1% (adverse reaction details) OR documented contraindication to permethrin 1%.
When relevant, include evidence of local known or suspected permethrin resistance.
Include supporting pharmacy claims when available (permethrin 1% fill dates and days supply) to demonstrate whether the initial step was attempted.

Definitions

Pediculus humanus capitis — Definition

TermPediculus humanus capitis

DefinitionHead lice and their ova of the scalp hair (indication stated in FDA‑approved labeling).

ContextIndication for Ovide (malathion) lotion per FDA‑approved labeling.

Initial step therapy — permethrin 1% requirement

RequirementMember must have filled at least a 1‑day supply of permethrin 1% under the prescription benefit within the past 60 days to bypass PA for Ovide.

Adjudication when metIf the initial step therapy requirement is met, the requested drug will be paid under the prescription benefit for that permethrin product rather than paid as Ovide without further PA.

When not metIf the patient does not meet the initial step therapy criteria, the claim will reject with a message that a prior authorization is required and PA criteria will be applied.

Exceptions that justify PA approval when step not metPA may be approved if the patient has failed permethrin 1%, is intolerant to it, has a contraindication to a trial of permethrin 1%, or there is known/suspected local resistance to permethrin 1%.

Background

Ovide (malathion) lotion is FDA‑approved for the treatment of Pediculus humanus capitis (head lice and their ova of the scalp hair). The policy frames Ovide as a later‑line option when topical permethrin 1% is not appropriate or has failed, and it is subject to prior authorization unless the initial step therapy requirement with permethrin 1% has been met.

Per the coverage criteria, prior authorization approval for Ovide requires documentation that the medication is being used for treatment of head lice and evidence of one of the following: inadequate response to permethrin 1%, intolerance to permethrin 1%, a contraindication to permethrin 1%, or known/suspected local resistance to permethrin 1%.

Revision History

2023-03-01policy_effective_date

Policy effective date published for Ovide (malathion) coverage criteria and step therapy requirements.

criteria_updateLatest

Covered with prior authorization when prescribed for Pediculus humanus capitis and when permethrin 1% trial is not documented or patient has inadequate response, intolerance, contraindication, or local resistance; clarified PA approval conditions.