CurrentBlue Cross Blue Shield - MassachusettsPolicy 062

Mupirocin prior authorization, step therapy, and quantity limits

Defines BCBSMA coverage, step therapy, and quantity limit requirements for mupirocin products for commercial members and explains prior authorization and exception (individual consideration) processes.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyMupirocin prior authorization, step therapy, and quantity limits

Policy CodePolicy 062

Change TypeNo material change

Effective DateOct 1, 2023

Next Review Date

Key ActionPrior authorization is required per the step therapy rules; providers may request coverage by calling or faxing Pharmacy Operations or submitting the Massachusetts standard prior authorization form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Step therapy requiredmupirocin products (general)

130 daysprior use look-back period

Policy #621BQuantity limits referenced

Phone/FaxPrior auth contact

Coverage Criteria

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Product-specific Step Therapy

Coverage and step requirements by product (BCBSMA Commercial Plan):

Mupirocin ointment (formulary): Mupirocin ointment is covered and designated QCD (Quality Care Dosing); covered with no step requirements for the formulary ointment product.

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Mupirocin cream is Step Therapy (ST) and QCD; requires prior use of ONE step medication OR history of use of any step 2 medication within the previous 130 days.prior use within 130 days

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Centany AT (mupirocin ointment): Centany AT requires prior use of ONE Step and ONE Step 2 medication.

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Centany (mupirocin ointment) - NFNC: Centany (non-formulary/non-covered) requires prior use of ONE Step and ONE Step 2 medication for consideration.

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If an exception (individual consideration) is approved to allow coverage of a non-preferred or non-formulary/non-covered mupirocin product, the member may be subject to a higher non-preferred cost share as outlined in the policy.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required per the step therapy rules. Providers may request coverage by calling Pharmacy Operations or submitting the Formulary Exception / Prior Authorization form via fax or mail to the addresses below.

Pharmacy Operations: Tel: 1-800-366-7778
Fax: 1-800-583-6289
Mail: Blue Cross Blue Shield of Massachusetts Pharmacy Operations Department, 25 Technology Place, Hingham, MA 02043
Applicable to Commercial Plans: Managed Care (HMO and POS), PPO and Indemnity, Medex with Rx plan, Managed Major Medical with Custom BCBSMA Formulary, Comprehensive Managed Major Medical with Custom BCBSMA Formulary, Managed Blue for Seniors with Custom BCBSMA Formulary

Step Therapy

Step Therapy Verification

Step therapy is enforced using prescription claim records to confirm prior use within the previous 130 days. For mupirocin products: mupirocin ointment (QCD) is Step 1 (covered with no requirements); mupirocin cream is Step 2 and requires prior use of ONE Step 1 medication or history of use of any Step 2 medication within the previous 130 days. Some branded mupirocin ointments require prior use of both a Step 1 and a Step 2 product.

Step therapy lookback period: 130 days
Mupirocin ointment (formulary) = Step 1, covered with no requirements
Mupirocin cream = Step 2; requires prior use of ONE Step 1 medication OR history of any Step 2 medication within 130 days
Certain branded mupirocin ointments (e.g., Centany) require prior use of ONE Step 1 and ONE Step 2 product

Documentation Required

Required Provider Documentation

When prescription claim data does not establish prior use or trial/failure of formulary alternatives, the provider must supply documentation. Documentation must include names and strengths of alternatives tried and failed (with dates if available) and specifics about the treatment failure. If a clinical reason prevents trial of formulary alternatives, the provider must describe the specific clinical rationale.

Include name and strength of alternatives tried and failed; include dates if available
Describe specifics of treatment failure for each alternative
If not trialing alternatives, provide detailed clinical reasons preventing the trial

Denial Risk

Denial Triggers

Requests may be denied if prior use of required step medications within the previous 130 days cannot be demonstrated using claims data and supporting provider documentation, or if documentation does not adequately justify why formulary alternatives were not tried.

Denial trigger: inability to demonstrate prior use of required step medications within 130 days
Denial trigger: submitted documentation fails to substantiate trial/failure of formulary alternatives or clinical justification for not trialing alternatives

Background

Mupirocin topical formulations (ointment and cream) are topical antibiotics used to treat certain skin infections. This policy establishes BCBSMA commercial-plan coverage rules for mupirocin products, including formulary designations, step therapy requirements, and a cross-reference to Quality Care Dosing (Medical Policy #621B) for quantity limits.

Formulary mupirocin ointment is designated Quality Care Dosing (QCD) and is covered without step requirements. Mupirocin cream and certain branded ointment products are subject to step therapy (ST) rules that require documented prior use of specified step medications (with a look-back of previous 130 days where applicable) before coverage will be approved.

Definitions

Quality Care Dosing (QCD) reference

Policy referenceQuality Care Dosing (quantity limits) — Medical Policy #621B

Applies toMupirocin products quantity limits

Action for providersSee Policy #621B for specific quantity limit rules when prescribing mupirocin products

Step Therapy (ST)

TermStep Therapy (ST)

DefinitionA coverage requirement that enforces prior use of specified lower‑tier or formulary medications before coverage of a higher‑tier product is allowed

VerificationEnforced using prescription claim records to confirm prior use; provider documentation required if claims data are insufficient

Non-formulary (NF)

TermNon‑formulary (NF)

DefinitionA product not on the plan formulary; coverage may require additional step requirements or individual consideration

ImplicationHigher cost share or non‑coverage may apply; exceptions handled per plan processes

Step Therapy Details

Product / Tier	Step requirement	Prior use verification / provider documentation
Mupirocin ointment (Formulary)	Step 1 — covered with no step requirements	Prior use verification not required for formulary ointment; standard QCD quantity limits apply (see policy #621B). If claims data are insufficient, provider documentation may be requested.
Mupirocin cream (Formulary — ST, QCD)	Step 2 — requires prior use of ONE step medication OR history of use of any step 2 medication within the previous 130 days	Plan verifies prior use using prescription claim records within the previous 130 days. If claim history is unavailable or does not establish prior use, the provider must supply documentation of trials/failures (including names, strengths, dates if available) or clinical reasons preventing trial of alternatives.
Centany AT (mupirocin ointment)	Requires prior use of ONE Step and ONE Step 2 medication	Prior use verified via prescription claims; additional provider documentation required when claim data do not demonstrate required prior use or trial/failure of formulary alternatives.
Centany (mupirocin ointment) — NFNC (non-formulary/non-covered)	Consideration requires prior use of ONE Step and ONE Step 2 medication	Plan will seek prescription claim evidence of prior use. For non-formulary consideration, provider must submit documentation of prior trials/failures and any clinical justification if claims do not establish required prior use.

OpenPayer

Mupirocin prior authorization, step therapy, and quantity limits

Coverage Criteria

Coding / Look-back

Provider Actions and Prior Authorization

Background

Definitions

Initial Therapy Criteria

Step Therapy Details

Quantity Limits

Site of Care