CurrentNeighborhood Health Plan of Rhode IslandPolicy 4830-D

Natroba (spinosad) step therapy for lice and scabies

Defines step therapy and prior authorization criteria for topical Natroba (spinosad) for treatment of head lice (≥6 months) and scabies (≥4 years) under the payer's pharmacy benefit.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNatroba (spinosad) step therapy for lice and scabies

Policy CodePolicy 4830-D

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionIf no permethrin 1% or 5% fill within the past 60 days, submit prior authorization with documentation of inadequate response, intolerance, contraindication, or local permethrin resistance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥6 mominimum age for head lice indication

≥4 yrminimum age for scabies indication

60 dayspermethrin lookback

permethrin 1%/5%required prior agent(s)

Coverage Criteria for Natroba (spinosad)

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Coverage for head lice (with prior authorization)

Covered when ALL of the following are met

Age and indication: Requested drug is prescribed for topical treatment of head lice in a patient that is 6 months of age or olderage >= 6 months

Permethrin 1% trial failure/intolerance/contraindication/resistance: Patient has experienced an inadequate treatment response to permethrin 1% OR intolerance to permethrin 1% OR a contraindication to permethrin 1% OR there is known/suspected local permethrin 1% resistanceN/A

If the patient has filled at least a 1‑day supply of permethrin 1% within the past 60 days under the benefit, the requested drug will be paid without prior authorization; otherwise prior authorization is required and claims may reject until PA criteria are satisfied.

Coverage for scabies (with prior authorization)

Covered when ALL of the following are met

Age and indication: Requested drug is prescribed for topical treatment of scabies in a patient that is 4 years of age or olderage >= 4 years

Permethrin 5% trial failure/intolerance/contraindication/resistance: Patient has experienced an inadequate treatment response to permethrin 5% OR intolerance to permethrin 5% OR a contraindication to permethrin 5% OR there is known/suspected local permethrin 5% resistanceN/A

If the patient has filled at least a 1‑day supply of permethrin 5% within the past 60 days under the benefit, the requested drug will be paid without prior authorization; otherwise prior authorization is required and claims may reject until PA criteria are satisfied.

No additional exclusions beyond those embedded in the coverage criteria are specified. Coverage is limited to the labeled indications and ages: head lice when prescribed for topical treatment in patients 6 months of age or older, and scabies when prescribed for topical treatment in patients 4 years of age or older. Approval also requires meeting one of the permethrin-related conditions (inadequate response, intolerance, contraindication to the appropriate permethrin strength, or known/suspected local permethrin resistance) as described in the criteria.

The payer enforces an initial step therapy lookback: if the member has filled at least a 1‑day supply of permethrin 1% or 5% within the past 60 days under the administered prescription benefit, the requested drug will be paid without prior authorization. If that initial step is not met, the claim will reject with an instruction that a prior authorization (PA) is required and the PA criteria must be submitted and met before the drug will be covered.

Coding and Permethrin Lookback

Referenced materials (no billing codes provided)mixed

N/A	No specific CPT/HCPCS/ICD-10 codes listed in document; references package inserts and external resources.

Permethrin lookback (inv-06)

Lookback window>= 60 days (patient must have filled a permethrin 1% or 5% supply within the past 60 days)

Required fill supplyAt least a 1‑day supply of permethrin 1% or permethrin 5% filled under the prescription benefit

PurposeSatisfies initial step therapy so requested topical agent will be paid without prior authorization

Provider Actions, Prior Authorization, and Documentation

Step Therapy

Initial Step: Permethrin Trial Required

If the patient has filled a prescription for at least a 1‑day supply of permethrin 1% or permethrin 5% within the past 60 days under a prescription benefit administered by CVS Caremark, the requested drug will be processed under that prescription benefit. This 60‑day lookback and 1‑day supply requirement is the initial step therapy requirement; document the permethrin fill when available.

Initial step: permethrin 1% (for head lice) or permethrin 5% (for scabies) filled within 60 days and at least a 1‑day supply

Denial Risk

Claim Rejection When Initial Step Not Met

Claims will reject when the initial permethrin step is not satisfied. A rejection message will indicate that prior authorization is required; providers must submit a PA request for the drug to the PA unit for evaluation if the initial step has not been met.

Claim rejection occurs when no permethrin fill (>=1 day supply) is found within the past 60 days

Prior Authorization

Prior Authorization Required

Prior authorization is required for requests that do not meet the initial permethrin step. Approval of the PA requires documentation that supports one of the coverage criteria (age and indication plus inadequate response, intolerance, contraindication, or local resistance). Submit the required documentation with the PA request to avoid delays.

Prior authorization required when initial step therapy not satisfied
PA evaluation applies coverage criteria (age, indication, and supporting clinical information)

Documentation Required

Required Clinical Documentation for Prior Authorization

Document the clinical rationale when submitting a PA. At minimum provide: - Patient age and indication (topical treatment of head lice or scabies) - Evidence of inadequate response to permethrin 1% (for head lice) or permethrin 5% (for scabies) - OR documentation of intolerance or allergy to the appropriate permethrin concentration - OR documentation of a contraindication to permethrin - OR evidence or local data indicating known or suspected permethrin resistance Include dates and details of prior permethrin treatment (fill date, product/concentration, supply days) and any supportive clinical notes or laboratory/epidemiologic evidence of resistance.

Patient age and indication (head lice ≥6 months; scabies ≥4 years)
Documentation of inadequate response to permethrin 1% (lice) or permethrin 5% (scabies)
Documentation of intolerance or allergy to permethrin
Documentation of contraindication to permethrin
Evidence of local or suspected permethrin resistance
Dates, product strength, and supply quantity of prior permethrin treatment
Relevant clinical notes supporting the above

Background

Natroba (spinosad) is a topical pediculicide referenced for treatment of ectoparasitic infestations. It is indicated for the topical treatment of head lice in patients 6 months of age and older and for the topical treatment of scabies in patients 4 years of age and older. Management guidance in the policy emphasizes standard supportive measures (for example, laundering clothing/bedding and combing to remove lice/nits for head lice; laundering bedding/clothing for scabies) and that coverage decisions depend on satisfying the age/indication and permethrin-related requirements described elsewhere in the policy.

Indication Definitions

Head lice indication (inv-12)

IndicationTopical treatment of head lice infestations

Minimum patient age6 months of age or older

Adjunctive managementUse as part of overall lice management (wash clothing/bedding, clean combs/brushes, use nit comb)

Scabies indication (inv-13)

IndicationTopical treatment of scabies infestations

Minimum patient age4 years of age or older

Adjunctive managementLaunder bedding, clothing, and towels used by affected persons in hot water or dry‑clean