Albendazole

POLICY NUMBER

L.5.01.505

Albendazole

Please perform a Formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.

DESCRIPTION

Albendazole is a broad-spectrum anthelmintic drug indicated for the treatment of parenchymal neurocysticercosis due to active lesions caused by larval forms of the pork tapeworm,Taenia solium, and for the treatment of cystic hydatid disease of the liver, lung, and peritoneum caused by the larval form of the dog tapeworm,Echinococcus granulosus.

POLICY

Albendazole is covered by BCBSMS at a quantity of 6 tablets per 180 days. A benefit appeal is required for consideration of additional doses above this quantity.

Albendazole may be approved at higher quantities when the individual meets the following criteria:

1. ONE of the following:

   1. The individual has a diagnosis of parenchymal neurocysticercosis due to active lesions caused by larval forms of the pork tapeworm, Taenia solium with supporting documentation in medical records; OR

   2. The individual has a diagnosis of cystic hydatid disease of the liver, lung, or peritoneum, caused by the larval form of the dog tapeworm, Echinococcus granulosus, with supporting documentation in medical records; AND

2. The dosage and duration requested does not exceed FDA-approved dosages by indication as outlined in the table below.

POLICY EXCEPTIONS

State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

11/01/2016: New policy added. Policy number L.5.01.505.

05/16/2017: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.

03/27/2018: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.

07/29/2020: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Added drug name to the top of the policy. Policy statements updated to add "albendazole" and to re-format approval criteria. Added "albendazole" to Policy Exceptions. Sources updated.

02/01/2023: Policy Exceptions updated to add the following: State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.

10/01/2024: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy title changed from "Albenza (albendazole)" to "Albendazole." Policy section updated to change "member" to "individual" and to remove Albenza from the coverage criteria. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders." Sources updated.

09/09/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy description updated regarding indications for Albendazole. Policy section updated with minor changes. Sources updated.

SOURCE(S)

Albenza prescribing information. Amedra Pharmaceuticals LLC. September 2019. Last accessed June 2025.

CODE REFERENCE

None