Emverm — CareFirst (Caremark)

Initial criteria

• The infection has been confirmed by a diagnostic or laboratory test (e.g., imaging scans, scotch tape test, blood, stool, or urine test)
• The request is for mebendazole (Emverm) in a patient age ≥ 2 years for a second course of therapy (first course of therapy administered within the past year) at a dose up to 2 tablets per day for two 3‑day treatments for Ancylostoma duodenale (hookworm), Ascaris lumbricoides (roundworm), Enterobius vermicularis (pinworm), Necator americanus (hookworm), or Trichuris trichiura (whipworm)
• OR the request is for albendazole for treatment of Hydatid Disease for a second course of therapy (first course of therapy administered within the past year) at a dose up to 4 tablets per day for three 28‑day cycles with 14‑day free intervals
• OR the request is for praziquantel (Biltricide) in a patient age ≥ 1 year for treatment of schistosomiasis, clonorchiasis, or opisthorchiasis for a quantity up to 36 tablets, a second day or course of therapy (first course of therapy administered within the past year)
• OR the request is for triclabendazole (Egaten) in a patient age ≥ 6 years for treatment of fascioliasis for a quantity up to 32 tablets, a second day or course of therapy (first course of therapy administered within the past year)

Approval duration

Albendazole: 4 months; Biltricide (praziquantel): 1 month; Egaten (triclabendazole): 1 month; Emverm (mebendazole): 1 month