Table 54: Pediculicides and Scabicides
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Drug Category: Dermatological
Medication Class/Individual Agents: Pediculicide/Scabicide
I. Prior-Authorization Requirements
Pediculicides and Scabicides |
Clinical Notes |
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Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
Centers for Disease Control and Prevention: Treatment of Head Lice (2016)1
Centers for Disease Control and Prevention: Treatment of Scabies (2016)2
1.Centers for Disease Control and Prevention. Treatment of Head Lice [guideline on the internet]. 2016. [cited 2017 Feb 10]. Available at: https://www.cdc.gov/parasites/lice/head/treatment.html 2. Centers for Disease Control and Prevention. Treatment of Head Scabies [guideline on the internet]. 2016. [cited 2017 Feb 10]. Available at: http://www.cdc.gov/parasites/scabies/health_professionals/meds.html. |
# | This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent. |
* | The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization. |
II. Therapeutic Uses
FDA-approved, for example:
- Head lice (lindane shampoo, malathion, Sklice, spinosad)
- Scabies (crotamiton lotion)
Note: The above list may not include all FDA-approved indications.
III. Evaluation Criteria for Approval
- All PA requests must include clinical diagnosis, drug name, dose, and frequency.
- A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
- For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
- Additional criteria may apply, depending upon the member’s condition and requested medication (see below).
crotamiton lotion
- Documentation of all of the following is required:
- appropriate diagnosis; and
- an inadequate response to permethrin 5% within the past 30 days; or
- an adverse reaction at any time or contraindication to permethrin 5%; and
- an inadequate response to oral ivermectin within the past 30 days; or
- an adverse reaction at any time or contraindication to oral ivermectin; and
- an inadequate response within the past 30 days or adverse reaction to Eurax cream; or
- clinical rationale for the use of the requested formulation over cream formulation.
lindane shampoo
- Documentation of all of the following is required:
- appropriate diagnosis; and
- an inadequate response or adverse reaction to a permethrin product or a pyrethrin/piperonyl butoxide product within the past 30 days; or
- an adverse reaction at any time or contraindication to both permethrin and pyrethrin/piperonyl butoxide products; and
- an inadequate response within the past 30 days, adverse reaction, or contraindication to malathion.
malathion
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ two years of age; and
- an inadequate response or adverse reaction to a permethrin product or a pyrethrin/piperonyl butoxide product within the past 30 days; or
- an adverse reaction at any time or contraindication to both permethrin and pyrethrin/piperonyl butoxide products.
SmartPA: Claims for malathion will usually process at the pharmacy without a PA request if the member is ≥ two years of age and has a history of a paid MassHealth pharmacy claim for a permethrin product or a piperonyl butoxide product within the last 30 days.†
Sklice and spinosad
- Documentation of all of the following is required:
- appropriate diagnosis; and
- member is ≥ six months of age; and
- an inadequate response or adverse reaction to a permethrin product or a pyrethrin/piperonyl butoxide product within the past 30 days; or
- an adverse reaction at any time or contraindication to both permethrin and pyrethrin/piperonyl butoxide products.
Original Effective Date: 07/2011
Last Revised Date: 02/2020
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Last updated 01/11/21