CurrentUnitedHealthcarePolicy 2024 P 2114-10

Prior authorization criteria for albendazole (Albenza) and mebendazole (Emverm)

UnitedHealthcare prior authorization program for anthelmintic medications Albenza (albendazole) and Emverm (mebendazole), listing covered diagnoses and specific approval durations and additional clinical rules. Applies to covered members per benefit plan and state mandates.

Policy Summary

PayerUnitedHealthcare

PolicyPrior authorization criteria for albendazole (Albenza) and mebendazole (Emverm)

Policy CodePolicy 2024 P 2114-10

Change TypeClarified; annual updates

Effective DateNov 1, 2024

Next Review Date

Key ActionPrior authorization is required for Albenza and Emverm; approvals are diagnosis-specific with specified authorization durations (one month, six months, or twelve months as listed).

POLICY UPDATE CHANGES

Authorization durations and covered indications updated over time; most recent P&T approval 8/2024 and effective date 11/1/2024.

20+Covered Indications (listed parasitic infections)

1-12 moAuthorization durations (varies by diagnosis)

2024-11-01Policy Effective Date

Coverage Summary

This policy (Program Number 2024 P 2114-10, effective 2024-11-01) defines UnitedHealthcare prior authorization criteria for anthelmintic agents albendazole (Albenza) and mebendazole (Emverm). Scope: coverage is covered with criteria and limited to the listed parasitic infection diagnoses with specified approval durations. Subject: prior authorization requirements and approval rules for Albenza and Emverm under member benefit plans and applicable state mandates.

Initial Therapy Criteria (by diagnosis)

General approval rule per diagnosis

Approvals are medication-specific and issued when the listed diagnosis is present; some diagnoses require prior failure/intolerance to OTC pyrantel pamoate or have medication-specific requirements:

A. Enterobius vermicularis (pinworm) - Albenza or Emverm

History of failure, contraindication or intolerance to over-the-counter pyrantel pamoate

B. Taenia solium and Taenia saginata (Taeniasis/Cysticercosis) - Albenza: Diagnosis of Taeniasis or Cysticercosis/Neurocysticercosis

Authorization will be issued for six months

Echinococcosis (Tapeworm) - Albenza or Emverm: Diagnosis of Hydatid Disease (Echinococcosis)

Authorization will be issued for six months

D. Ancylostoma/Necatoriasis (Hookworm): Diagnosis of Ancylostoma/Necatoriasis (Hookworm)

Emverm: Authorization will be issued for one month; Albenza: Authorization will be issued (document lists approval for Albenza; change log notes Ancylostoma/Necatoriasis authorization changed to six months for Albenza)

Ascariasis (Roundworm) - Albenza or Emverm: Diagnosis of Ascariasis (Roundworm)