ivermectin tablets (generic) — Cigna
Pediculosis caused by pediculus humanus corporis (body lice)
Initial criteria
- Approval is recommended for prescription benefit coverage of ivermectin tablets when used for an FDA-approved indication or other uses with supportive evidence, as listed below.
- For Onchocerciasis infection: approve if used for treatment of infection due to Onchocerca volvulus.
- For Strongyloidiasis: approve if used for treatment of intestinal (non-disseminated) strongyloidiasis due to Strongyloides stercoralis.
- For Ascariasis: approve if used for treatment of infection due to Ascaris species.
- For Demodex folliculorum infection: approve if used for treatment of Demodex folliculorum infection.
- For Enterobiasis (pinworm infection): approve if used for treatment of pinworm infection.
- For Gnathostomiasis: approve if used for treatment of gnathostomiasis.
- For Hookworm-related cutaneous larva migrans: approve if used for treatment of hookworm-related cutaneous larva migrans.
- For Mansonella ozzardi infection: approve if used for treatment of infection due to Mansonella ozzardi.
- For Mansonella streptocerca infection: approve if used for treatment of infection due to Mansonella streptocerca.
- For Pediculosis: approve if the patient meets ONE of the following (A, B, or C): A) Infection caused by pediculus humanus capitis (head lice); OR B) Infection caused by pediculus humanus corporis (body lice); OR C) Pediculosis pubis caused by Phthirus pubis (pubic lice).
- For Scabies: approve if the patient meets ONE of the following (A, B, C, D, or E): A) Classic scabies; OR B) Treatment-resistant scabies; OR C) Unable to tolerate topical treatment; OR D) Crusted scabies (Norwegian scabies); OR E) Using ivermectin for prevention and/or control of scabies.
- For Trichuriasis: approve if used for treatment of infection due to Trichuris species.
- For Wucheria bancrofti infection: approve if used for treatment of Wucheria bancrofti infection (lymphatic filariasis).
Approval duration
1 month