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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
Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

Drug
Notes
crotamiton cream Eurax test  
crotamiton lotion Eurax PA   BP
ivermectin lotion Sklice PA   A90
lindane shampoo PA   A90
malathion Ovide PA   A90
permethrin test   *, A90
permethrin cream Elimite test   # , A90
piperonyl butoxide / pyrethrins test   *, A90
spinosad Natroba PA   A90

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.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 
* The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization.
 
A90 Allowable 90-day supply. Dispensing in up to a 90-day supply is allowed. May not include all strengths or formulations. Quantity limits and other restrictions may apply.
 

II. Therapeutic Uses

FDA-approved, for example:  

  • Head lice (ivermectin lotion, lindane shampoo, malathion, spinosad)
  • Scabies (crotamiton lotion)

Non-FDA-approved, for example:

  • Pubic lice (lindane shampoo)

Note: The above lists may not include all FDA-approved and non-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.
  • Dispensing in a 90-day supply of medication may be mandated or allowable for agents in this therapeutic class (designated by M90 or A90, respectively, in the Drug Notes section above). Applicable quantity limits are described below as units per day, per month, per 28 days, or as clinically appropriate, and may be extrapolated for fills of longer day supply. 
  • 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 diagnosis and/or requested medication (see below). Other factors, including rebate and FDA-approval status may change independently of scheduled MassHealth updates, which may result in additional restrictions.

 

crotamiton lotion

  • Documentation of all of the following is required: 
    • appropriate diagnosis; and
    • inadequate response to permethrin 5% within the last 30 days; or
    • adverse reaction or contraindication to permethrin 5%; and
    • inadequate response to oral ivermectin within the last 30 days; or
    • adverse reaction or contraindication to oral ivermectin; and
    • inadequate response within the last 30 days or adverse reaction to Eurax cream.
SmartPA: Claims for crotamiton lotion will usually process at the pharmacy without a PA request if the member has a history of paid MassHealth pharmacy claims for permethrin 5%, oral ivermectin, and Eurax cream within the last 30 days.†

 

ivermectin lotion and spinosad

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ six months of age; and
    • inadequate response or adverse reaction to a permethrin product or a piperonyl butoxide/pyrethrins product within the last 30 days; or
    • adverse reaction at any time or contraindication to both permethrin and piperonyl butoxide/pyrethrins products. 
 
SmartPA: Claims for ivermectin lotion 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 a paid MassHealth pharmacy claim for a permethrin product or a piperonyl butoxide/pyrethrins product within the last 30 days.†

 

lindane shampoo

  • Documentation of all of the following is required for a diagnosis of of head lice:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to a permethrin product or a piperonyl butoxide/pyrethrins product within the last 30 days; or
    • adverse reaction at any time or contraindication to both permethrin and piperonyl butoxide/pyrethrins products; and
    • inadequate response within the last 30 days, adverse reaction, or contraindication to malathion. 

 

  • Documentation of all of the following is required for a diagnosis of public lice:
    • appropriate diagnosis; and
    • inadequate response or adverse reaction to a permethrin product or a piperonyl butoxide/pyrethrins product within the last 30 days; or
    • adverse reaction at any time or contraindication to both permethrin and piperonyl butoxide/pyrethrins products; and
    • inadequate response within the last 30 days, adverse reaction, or contraindication to a second lice treatment available without PA.

 

malathion

  • Documentation of all of the following is required:
    • appropriate diagnosis; and
    • member is ≥ two years of age; and
    • inadequate response or adverse reaction to a permethrin product or a piperonyl butoxide/pyrethrins product within the last 30 days; or
    • adverse reaction at any time or contraindication to both of the following: permethrin product, piperonyl butoxide/pyrethrins product.

       

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/pyrethrins product 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: 04/2023

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Last updated 09/25/23

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