CurrentAvMedPolicy N/A

Topical Antibiotic Prior Authorization (Altabax, Xepi)

This form governs prior authorization and step-edit requests for topical antibiotics (Altabax and Xepi) for AvMed members; it applies to prescribers requesting coverage for these products.

Policy Summary

PayerAvMed

PolicyTopical Antibiotic Prior Authorization (Altabax, Xepi)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the prior authorization form and provide required clinical documentation, including evidence of mupirocin trial or contraindication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2drugs listed

30 gquantity limit

9m / 2mmin ages (Altabax/Xepi)

Coverage and Approval Criteria

Approval criteria

Covered when ALL of the following are met

Age requirement: If requesting Altabax, member is 9 months of age or older; if requesting Xepi, member is 2 months of age or older.Altabax >= 9 months; Xepi >= 2 months

Diagnosis and pathogen documentation: Member has a diagnosis of impetigo with clinical documentation of infection due to Staphylococcus aureus or Streptococcus pyogenes.

To support each line checked, all documentation, including lab results, diagnostics, and/or chart notes, must be provided or request may be denied.

Step therapy failure or contraindication: Member has tried and failed, or has a contraindication or intolerance to mupirocin 2% ointment, verified by chart notes or pharmacy paid claims.

Policy Summary

PayerAvMed

PolicyTopical Antibiotic Prior Authorization (Altabax, Xepi)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete the prior authorization form and provide required clinical documentation, including evidence of mupirocin trial or contraindication.

SourceLink

On This Page

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Previous therapies will be verified through pharmacy paid claims or submitted chart notes.

Use of medication samples to initiate therapy does not satisfy the plan's step therapy or prior authorization requirements. Requests based solely on sample use will not be accepted as evidence of prior trial or failure; documented trial, failure, or contraindication must be supported by chart notes or pharmacy paid claims.

Diagnosis, Codes and Quantity Limits

Diagnosis codes (provider-supplied)ICD-10

ICD code

Member diagnosis ICD code (provider to supply)

Quantity limit — 30 grams per prescription

Quantity limit30 grams per prescription

Perper prescription

Applies toTopical antibiotics (Altabax, Xepi and others subject to PA)

Prescriber Responsibilities and Prior Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed topical antibiotics. Providers must complete and sign the PA request form (preprinted signature stamps are not valid) and fax it to 1-305-671-0200. Incomplete, incorrect, or illegible information (including missing phone/fax numbers) can delay processing or result in denial.

Altabax (retapamulin) 1% ointment
Xepi (ozenoxacin) 1% cream
Fax completed form to 1-305-671-0200

Step Therapy

Step Therapy: Mupirocin Required First

Member must have tried and failed, or have a documented contraindication or intolerance to mupirocin 2% ointment. This must be verified by chart notes or pharmacy paid claims. Use of samples to start therapy does not satisfy step-edit requirements.

Step edit requires mupirocin 2% ointment trial or documented contraindication/intolerance
Verification via chart notes or pharmacy paid claims required
Samples do not meet step-edit criteria

Documentation Required

Required Fields and Supporting Documentation

Prescriber must provide all required fields and supporting documentation on the form: prescriber signature (handwritten, not preprinted stamp), member and prescriber details, drug form/strength, dosing schedule, length of therapy, diagnosis and ICD code (if applicable), weight, date, and quantity requested. Clinical documentation to support requested indications (lab results, diagnostics, chart notes) must be attached.

Prescriber signature (handwritten)
Drug form/strength, dosing schedule, length of therapy, quantity (30 g per Rx limit)
Diagnosis and ICD code, weight, date
Clinical documentation (lab results, diagnostics, chart notes) to support criteria

Denial Risk

Incomplete or Insufficient Documentation Risks Delay or Denial

If the request form is incomplete, incorrect, or illegible, or if required clinical documentation is missing, processing may be delayed or the request may be denied. Verify all information before submission to avoid delays.

Incomplete/incorrect/illegible forms risk delay or denial
Missing clinical documentation may lead to denial
Ensure phone and fax numbers on form are correct

Clinical Background

This policy applies to coverage decisions for topical antibiotics used to treat impetigo. Approval requires documentation that the infection is due to Staphylococcus aureus or Streptococcus pyogenes, and that the patient has either tried and failed, or has a documented contraindication or intolerance to mupirocin 2% ointment, verified by chart notes or pharmacy paid claims.

Key Definitions

Definition — impetigo with documented infection

TermImpetigo with documented infection by Staphylococcus aureus or Streptococcus pyogenes

Required evidenceClinical documentation identifying Staphylococcus aureus or Streptococcus pyogenes

VerificationPrevious therapies and documentation may be verified through pharmacy paid claims or submitted chart notes

Initial Therapy Requirements

Initial therapy requirements

Initial coverage requires:

Age: Altabax: >=9 months; Xepi: >=2 months.Altabax >= 9 months; Xepi >= 2 months

Diagnosis of impetigo with documentation of infection by Staphylococcus aureus or Streptococcus pyogenes.

Prior therapy: Trial and failure of, or documented contraindication/intolerance to, mupirocin 2% ointment verified by chart notes or pharmacy paid claims.

Use of samples to initiate therapy does not meet step edit/preauthorization criteria.

Step Therapy Requirements

Step	Requirement
1	Documented trial and failure of mupirocin 2% ointment, or documented contraindication/intolerance to mupirocin 2% ointment, verified by chart notes or pharmacy paid claims.

Per-prescription Quantity Limits

Topical antibiotic (per prescription) — Quantity

Topical antibiotic (per prescription)30 grams

Measurement unitgrams

ContextQuantity limit applies to topical antibiotics prescribed (per prescription)