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Mandatory Generic/Member Pays the Difference (MPTD) Exception Prior Authorization Program Summary
Policy Number: PH-1013
This program applies to Blue Partner, Commercial, GenPlus, NetResults A series, SourceRx and Health Insurance Marketplace formularies.
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
1/1/2024 |
|
FDA APPROVED INDICATIONS AND DOSAGE
Agent(s) |
FDA Indication(s) |
Notes |
Ref# |
Stromectol® (ivermectin) Tablet |
|
Generic equivalent available |
1 |
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
CLINICAL RATIONALE
Ivermectin |
Most strongyloidiasis and onchocerciasis infections are treated with a single dose. If the infection is not cleared, a single dose retreatment at 3 months for onchocerciasis, and a single dose retreatment at 3 or 12 months for strongyloidiasis can be used.(2)
The Center for Disease Control and Prevention reports that the highest 95th percentile weight by age is 127.6 kg for females and 139.9 kg for males.(3)
|
Safety |
Ivermectin is contraindicated in patients who are hypersensitive to any component of this product.(1) |
REFERENCES
Number |
Reference |
1 |
Stromectol prescribing information. Merck Sharp & Dohme Corp. March 2022. |
2 |
IBM Micromedex. Ivermectin. |
3 |
National Center for Health Statistics. Center for Disease Control and Prevention. Available at: https://www.cdc.gov/nchs/fastats/body-measurements.htm.. |
POLICY AGENT SUMMARY PRIOR AUTHORIZATION
Target Brand Agent(s) |
Target Generic Agent(s) |
Strength |
Targeted MSC |
Available MSC |
Final Age Limit |
Preferred Status |
|
||||||
Stromectol |
ivermectin tab |
3 MG |
M ; N ; O ; Y |
O ; Y |
|
|
CLIENT SUMMARY – PRIOR AUTHORIZATION
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
Stromectol |
ivermectin tab |
3 MG |
Blue Partner ; Commercial ; GenPlus ; Health Insurance Marketplace ; NetResults A Series ; SourceRx |
PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
|
Target Agent(s) will be approved when ALL of the following are met:
Compendia Allowed: AHFS or DrugDex with 1 or 2a level of evidence Length of Approval: 1 month |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment
BCBSAL _ Commercial _ CS _ Ivermectin _PA _ProgSum_ 1/1/2024