CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Stromectol (ivermectin) — Prior Authorization with Quantity Limit (coverage criteria)

Defines prior authorization and quantity limit criteria for oral ivermectin (Stromectol) for the payer's pharmacy benefit; affects prescribers and pharmacists requesting coverage for ivermectin fills.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyStromectol (ivermectin) — Prior Authorization with Quantity Limit

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain an initial prior authorization with a quantity limit of 9 tablets per 75 days for oral ivermectin (Stromectol).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9quantity limit

75-dayfill period

4909-Cduration code

excludedCOVID-19 use

Coverage Criteria for Ivermectin (Stromectol)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage prerequisites: 1) Requested use aligns with FDA‑approved indications (intestinal strongyloidiasis or onchocerciasis) OR other accepted non‑COVID indications; 2) Prior authorization obtained (initial prior authorization with quantity limit); 3) Quantity does not exceed 9 tablets per 75 days (75‑day duration applies to a 90‑day fill); 4) Requested use is NOT for prevention or treatment of COVID‑19.

Derived from policy sections on indications, PA type, quantity limits, and COVID‑19 exclusion.

Prescriber and Pharmacist Actions / Prior Authorization

Prior Authorization

Initial Prior Authorization Required

Initial prior authorization required for new prescriptions. Quantity limit applies: 9 tablets per 75 days (the 75-day window corresponds to a 90-day fill period).

Type: Initial Prior Authorization with Quantity Limit
Quantity limit: 9 tablets per 75 days (75-day window used for a 90-day fill period)

Note

(Placeholder) No additional provider action or summary provided in source.

Prior Authorization

Prior Authorization and Quantity Limits

Prior authorization required as an initial PA with a quantity limit. Duration of approval: 3 months per DQA code 4909-C.

Initial PA with quantity limit: 9 tablets per 75 days
Duration of approval (DQA): 3 months (code 4909-C)

Denial Risk

COVID-19 Use Exclusion

Authorization may be denied if the requested drug is being prescribed for the prevention or treatment of COVID-19.

Do not authorize for prevention or treatment of COVID-19

Clinical Definitions

inv-11: Strongyloidiasis (intestinal) — definition and indication for Stromectol

DefinitionInfection of the intestinal tract caused by the nematode Strongyloides stercoralis

FDA indicationStromectol is indicated for the treatment of intestinal (non-disseminated) strongyloidiasis

Clinical noteUsed to treat infections due to Strongyloides stercoralis (intestinal strongyloidiasis)

inv-12: Onchocerciasis — definition and note that Stromectol has no activity against adult parasites

DefinitionInfection due to the nematode Onchocerca volvulus (onchocerciasis)

FDA indicationStromectol is indicated for the treatment of onchocerciasis

Activity limitationStromectol has no activity against adult Onchocerca volvulus parasites

Revision History

2024-01policy updateLatest

Document version labeled 'Ivermectin (Oral) PA with Limit COVID19 Policy 4909-C UDR 01-2024' published; duration of approval code 4909-C (3 months) and 75-day quantity limit for 90-day fills confirmed.

2023-12-04reference update

References and guidance sources (including WHO and NIH COVID-19 treatment guidelines) accessed and cited in policy documentation.