Mupirocin step therapy and quantity limits
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BCBSMA policy governing step therapy, formulary status, and quantity dosing rules for mupirocin products for commercial members; includes prior authorization and individual exception processes.
No material clinical or coverage changes in this revision.
Coverage and Formulary Rules
Step Therapy / Formulary Criteria
Coverage and step therapy rules for mupirocin products
Formulary status: Covered, QCD
Formulary status: ST, QCD
NFNC products require trial of both tiers before coverage
This policy applies to BCBSMA commercial products with the Blue Cross Blue Shield of Massachusetts formulary, including Managed Care (HMO/POS), PPO/EPO, Indemnity, Medex with Rx plans, and Managed Blue for Seniors. This policy does not apply to Medicare Advantage plans.
Requests based solely on the use of medication samples will not meet the coverage criteria for an individual exception and therefore will not be approved. Providers must submit additional clinical information demonstrating medical necessity for review when seeking coverage outside the criteria.
Lookback and Coding Notes
What Providers Must Do
Prior Authorization and Submission
Certain mupirocin products require prior authorization or step therapy. Providers may submit the Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or Form #434 by print and fax. For assistance contact Pharmacy Operations: Phone: 1-800-366-7778 • Fax: 1-800-583-6289.
- Massachusetts Standard Form for Medication Prior Authorization Requests (eForm) or Form #434
- Phone: 1-800-366-7778 • Fax: 1-800-583-6289
Step Therapy Requirements
Mupirocin ointment (including branded and generic ointment formulations) is covered without step therapy requirements. Mupirocin cream is subject to step therapy: prior use of ONE Step 1 medication or documentation of prior use of any Step 2 medication within the previous 130 days is required. Specific non-formulary ointment products (e.g., Centany AT, Centany) may require prior use of one Step 1 and one Step 2 agent.
- Mupirocin ointment = Covered, no requirements
- Mupirocin cream = Step Therapy (requires prior use of ONE Step 1 medication OR prior use of any Step 2 medication within previous 130 days)
- Centany / Centany AT (non-formulary ointments) = Requires prior use of ONE Step 1 and ONE Step 2
Required Documentation
When prescription claim history does not establish prior use within the required 130-day window or does not document trial and failure of formulary alternatives, the provider must submit supporting documentation. Acceptable documentation includes chart notes, lab results, or other clinical information showing trials, dates, doses, and reasons for discontinuation or failure of prior therapies.
- If prescription claim data unavailable or insufficient, submit chart notes, lab results, or other clinical documentation
- Include medication names, strengths, dates, duration, and reason for failure or contraindication
Samples and Exception Requests
Requests based solely on samples will not meet coverage criteria for an exception. Lack of supporting documentation or inability to demonstrate required prior use/trial and failure of formulary alternatives may result in denial. For atypical patients, submit an individual consideration request with comprehensive supporting clinical information.
- Sample-only requests are not sufficient for exception requests
- Provide full clinical rationale and documentation for individual consideration requests
Policy Background
This policy addresses formulary placement, step therapy, and quantity-dosing rules for topical mupirocin formulations used to treat localized skin infections. Mupirocin ointment is formulary-preferred and is covered with no step requirements; formulary quantity limits are managed per the referenced Quality Care Dosing guidelines (Medical Policy #621B). Mupirocin cream is subject to step therapy and requires prior use of either one Step 1 medication or prior use of any Step 2 medication within the previous 130 days. Branded ointments (Centany / Centany AT) are designated non-formulary (NFNC) and require documented trials of one Step 1 and one Step 2 medication before consideration for coverage. Prior use should be demonstrated via prescription claims when available; if claim data are unavailable, provider documentation (for example, chart notes or medication records) may be accepted to establish prior use.
Key Terms
Initial Therapy and Preferred Agents
Initial therapy
Formulary-preferred initial agents and lookback requirements
Use quantity limits per Policy #621B if applicable
Step Therapy Operational Details
| Requirement | Evidence of Prior Use |
|---|---|
| Prior use requirement for step therapy | |
| Prior use must be demonstrated via prescription claims or, when claims are unavailable, provider documentation (e.g., chart notes, medication history). |
Quantity and Dosing Limits
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