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Drug Category: Dermatological

Medication Class/Individual Agents: Pediculicide/Scabicide

I. Prior-Authorization Requirements

 Pediculicides and Scabicides

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

crotamiton Eurax PA  
ivermectin lotion Sklice PA  
lindane shampoo PA  
malathion Ovide PA  
permethrin * test  
permethrin cream Elimite # test  
piperonyl butoxide / pyrethrins * test  
spinosad Natroba PA  

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

  • Pyrethrins and permethrin are first-line treatments; however, a second course of therapy may be needed to kill newly hatched lice.
  • Benzoyl alcohol is pediculicidal but not ovicidal. A second treatment is necessary after the first treatment to kill newly hatched lice.
  • Ivermectin lotion is not ovicidal, but prevents newly hatched lice from surviving. It should not be used for retreatment without talking to a health care provider.
  • Malathion is pediculicidal and partially ovicidal. Retreatment may be necessary if the first treatment is unsuccessful.
  • Spinosad is pediculicidal and ovicidal. Therefore, retreatment is often not needed. Repeat treatment should only be given if live lice are seen seven days after the first treatment.
  • Lindane is not recommended as a first-line treatment for head lice due to potential neurotoxic reactions. Its use should be restricted to patients who have failed treatment or cannot tolerate other medications.

Centers for Disease Control and Prevention: Treatment of Scabies (2016)2

  • Permethrin is the first-line treatment for scabies, killing scabies mites and eggs. It is FDA-approved for the treatment in patients at least two months of age. Two (or more) applications, each about a week apart, may be necessary to eliminate all mites.
  • Crotamiton is FDA-approved for the treatment of scabies in adults, but not for treatment in children. Frequent treatment failure has been reported with this agent.
  • Lindane is not recommended as a first-line therapy. Overuse, misuse or accidental ingestion can be toxic to the nervous system; its use should be restricted to patients who have failed treatment or cannot tolerate other medications.
  • Oral ivermectin is a safe and effective treatment for scabies. The safety of ivermectin in children weighing less than 15 kg and in pregnant women has not been established.

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.

 
Table Footnotes
# 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)

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

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.
  • 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

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • an inadequate response to a permethrin 5% product within the past 30 days; or
    • an adverse reaction at any time or contraindication to a permethrin 5% product; and
    • an inadequate response to oral ivermectin within the past 30 days; or
    • an adverse reaction at any time or contraindication to oral ivermectin.
SmartPA: Claims for crotamiton will usually process at the pharmacy without a PA request if the member has a history of a paid claim for permethrin 5% and oral ivermectin within the last 30 days.

 

Lindane shampoo

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • an inadequate response or adverse reaction to permethrin or pyrethrin/piperonyl butoxide within the past 30 days; or
    • an adverse reaction at any time or contraindication to both permethrin and pyrethrin/piperonyl butoxide; and
    • an inadequate response or adverse reaction to malation within the past 30 days; or
    • an adverse reaction at any time or contraindication to malation. 

     

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 permethrin or pyrethrin/piperonyl butoxide within the past 30 days; or
    • an adverse reaction at any time or contraindication to both permethrin and pyrethrin/piperonyl butoxide.

       

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 paid claims for permethrin or piperonyl butoxide within the last 30 days.

 

Sklice, 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 one of the following within the past 30 days: permethrin, pyrethrin/piperonyl butoxide or malathion; or
    • an adverse reaction at any time or contraindication to all of the following: permethrin, pyrethrin/piperonyl butoxide and malathion. 
 
SmartPA: Claims for Sklice, and spinosad will usually process at the pharmacy without a PA request if the member is ≥ six months of age and has a history of paid claims for malathion, permethrin or piperonyl butoxide within the last 30 days.
 
Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.


Original Effective Date: 07/2011

Last Revised Date: 08/2019


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Last updated 11/18/19