Centene minocycline coverage & Prior Auth

Coverage and Authorization Criteria

Continuation Therapy - Acne

Covered when ALL of the following are met:

Acne continuation criteria: 1. Member currently receiving medication via Centene benefit or member has previously met initial approval criteria or is in a continuity of care circumstance; 2. Request is for minocycline ER (Solodyn, Ximino) or Minolira; 3. Member is responding positively to therapy; 4. If request is for a dose increase, new dose does not exceed 135 mg per day.

Continuation Therapy - Periodontitis

Covered when ALL of the following are met:

Arestin continuation criteria: 1. Member currently receiving medication via Centene benefit or member has previously met initial approval criteria or is in a continuity of care circumstance; 2. Request is for Arestin; 3. Member has not received 4 scaling and root planing procedures in the last 365 days; 4. Dose is individualized depending on the size, shape, and number of pockets being treated.

Continuation Therapy - Rosacea

Covered when ALL of the following are met:

Rosacea continuation criteria: 1. Member currently receiving medication via Centene benefit or member has previously met initial approval criteria or is in a continuity of care circumstance; 2. Request is for Zilxi or Emrosi; 3. Member is responding positively to therapy; 4. If request is for a dose increase, new dose does not exceed: (a) Zilxi: 1 can per month; or (b) Emrosi: 40 mg (1 capsule) per day.

Other Indications

Covered when ONE of the following is met:

Other indications pathway: 1. If the drug has undergone a recent label change (within 6 months) not yet reflected in this policy, follow the applicable no-coverage or non-formulary policy for the relevant line of business per formulary status; 2. If the requested use is not listed elsewhere in this policy and criterion 1 does not apply, refer to the off-label use policy for the relevant line of business (CP.CPA.09 for commercial, HIM.PA.154 for marketplace, CP.PMN.53 for Medicaid).

Requests for uses that are not FDA‑approved and are not addressed by this policy are not authorized unless the provider submits sufficient clinical documentation of efficacy and safety per the applicable off‑label use policies: CP.CPA.09 (Commercial), HIM.PA.154 (Health Insurance Marketplace/HIM), or CP.PMN.53 (Medicaid), or unless coverage is established in the member's evidence of coverage.

Arestin (minocycline microspheres) is excluded from coverage for all HIM plans except Florida, where it is treated as non‑formulary and may follow this policy's criteria and duration when applicable. In addition, Arestin is excluded from the pharmacy benefit for the Commercial line of business; consult the policy history and line‑of‑business notes for any applicable exceptions.

When state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, the state Medicaid coverage provisions take precedence. Providers should refer to the applicable state Medicaid manual for any differing coverage rules.

inv-11: Max daily dose (minocycline ER)

Max daily dose (minocycline ER)135 mg per day

Applies toMinocycline ER products (Solodyn, Ximino, Minolira)

ContextLimit referenced in Acne Vulgaris initial and continuation criteria

inv-12: Max supply (Zilxi)

Max supply (Zilxi)1 can per month

Product formZilxi foam 1.5% (30 g can)

IndicationTreatment of inflammatory lesions of rosacea in adults

inv-13: Max dose (Emrosi)

Max dose (Emrosi)40 mg (1 capsule) per day

Product formEmrosi extended-release capsule, 40 mg strength

IndicationTreatment of inflammatory lesions of rosacea in adults

inv-14: Max oral ER dose

Max oral ER dose1 mg/kg/day up to 135 mg/day

Dosing recommendationApproximately 1 mg/kg PO once daily for 12 weeks (weight-based tablet/capsule strengths)

Applies toOral extended-release minocycline (Solodyn, Ximino, Minolira)

Initial Authorization Requirements

Oral ER minocycline dosing

Oral extended-release minocycline dosing guidance:

ER oral dosing general: Recommended dosage approximately 1 mg/kg PO once daily for 12 weeks for acne vulgaris; tablet/capsule strengths correspond to weight bands to approximate 1 mg/kg. Maximum: 1 mg/kg/day up to 135 mg/day.maximum 1 mg/kg/day up to 135 mg/day

Continuation Therapy Requirements

Continuation Therapy

Continuation therapy — covered when ALL applicable indication-specific criteria are met:

Acne continuation: 1. Member currently receiving medication via Centene benefit or previously met initial approval criteria or in a continuity of care circumstance; 2. Request is for minocycline ER (Solodyn, Ximino) or Minolira; 3. Member is responding positively to therapy; 4. Dose limits apply (<=135 mg/day).

Periodontitis continuation: 1. Member currently receiving medication via Centene benefit or previously met initial approval criteria or in a continuity of care circumstance; 2. Request is for Arestin; 3. Member has not received 4 scaling and root planing procedures in the last 365 days; 4. Dose is individualized based on pockets treated.

Rosacea continuation: 1. Member currently receiving medication via Centene benefit or previously met initial approval criteria or in a continuity of care circumstance; 2. Request is for Zilxi or Emrosi; 3. Member is responding positively to therapy; 4. Dose limits apply (Zilxi 1 can/month; Emrosi 40 mg/day).

Step Therapy and Prior Treatments

Requirement	Details
Trial or contraindication to prior/preferred therapies required before authorization
Acne: Member must use immediate‑release (IR) minocycline unless contraindicated or adverse effects; failure of a ≥4 week trial of one additional preferred oral tetracycline (e.g., IR doxycycline). Dose limit: ≤135 mg/day.
Periodontitis (Arestin): Intolerance or contraindication to sub‑antimicrobial dose doxycycline (20 mg PO BID) required; Arestin prescribed as adjunct to scaling and root planing with individualized dosing.
Rosacea (Zilxi or Emrosi): Failure of ≥6 consecutive weeks of two alternatives (oral doxycycline, topical metronidazole, topical ivermectin, topical azelaic acid) at maximally tolerated doses required. Dose limits: Zilxi 1 can/month; Emrosi 40 mg/day.

Policy history note	Effect on step therapy
Policy documents record step therapy requirements for acne, periodontitis, and rosacea as part of initial authorization criteria.
Arestin: policy history clarifies exclusions/LOB restrictions (excluded for HIM except FL where non‑formulary; excluded for Commercial pharmacy benefit).
Illinois HIM (per IL HB 5395): step therapy requirements do not apply for Illinois HIM requests effective 1/1/2026 — a bypass to the step edits was added in policy history.

Provider Requirements, Documentation and Alerts

Prior Authorization

Prior Authorization Required

Prior authorization is required. Approval is granted only when specified diagnostic, age, dosing, and step therapy criteria in the policy are met for the requested indication.

Prior authorization required for requests of Solodyn, Ximino, Minolira, Arestin, Emrosi, and Zilxi per policy criteria.
Provider must submit supporting documentation (office chart notes, lab results, or other clinical information) demonstrating member meets all approval criteria.

Note

Coverage / Exclusion Notes

Arestin is excluded for Health Insurance Marketplace (HIM) plans in all states except Florida where it is non-formulary and may follow this policy for coverage criteria and duration. Arestin is excluded for the Commercial line of business on the pharmacy benefit.

Arestin excluded for all HIM plans except FL (can be NF in FL and follow policy).
Arestin excluded for Commercial line of business on the pharmacy benefit.

Dosing, Limits and Coding Notes

inv-11: Max daily dose (minocycline ER)

Max daily dose (minocycline ER)135 mg per day

Referenced inAcne Vulgaris initial and continuation criteria as dose limit

Dose checkAuthorization denied if dose exceeds 135 mg/day per policy criteria

inv-12: Max supply (Zilxi)

Max supply (Zilxi)1 can per month

Product availabilityZilxi foam: 1.5% (30 g can)

Continuation limit

Quantity and Unit-Dose Limits

inv-38: Zilxi — 1 can (max supply)

Zilxi quantity limit1 can (30 g) per month

FormulationMinocycline foam 1.5% in 30 g can

IndicationTopical treatment for inflammatory lesions of rosacea in adults

inv-39: Soolantra (ivermectin cream) example — 1 g/day

Soolantra example amount1 g/day

ContextListed in Appendix as dosing example for ivermectin cream (Soolantra) for rosacea

Use

Administration Setting

Billing Rule

Arestin: in‑office local application using unit‑dose cartridges

Arestin is administered in‑office by an oral health care professional as a local application using unit‑dose cartridges during scaling and root planing procedures.

Arestin is provided as a dry powder in unit‑dose cartridges inserted into a cartridge handle mechanism for application.

Note

Topical formulations: patient‑applied at home per labeling

Topical minocycline formulations (e.g., Zilxi, Emrosi) are applied by the patient at home according to labeling — typically once daily (Zilxi) or as prescribed for topical/oral regimens.

Zilxi: apply as a thin layer to affected facial areas once daily.
Emrosi dosing per product labeling (oral capsule strengths noted in product availability).

Clinical Background and Definitions

Minocycline formulations are tetracycline‑class antibiotics with distinct product approvals: oral extended‑release formulations (e.g., Solodyn, Ximino, Minolira) are FDA‑labeled for inflammatory lesions of non‑nodular moderate to severe acne vulgaris in patients aged ≥12 years; Arestin (minocycline microspheres) is a locally applied, unit‑dose cartridge product indicated as an adjunct to scaling and root planing to reduce pocket depth in adult periodontitis; and topical minocycline products (e.g., Emrosi, Zilxi) are indicated for treatment of inflammatory lesions of rosacea in adults. Safety data for some oral ER products are limited beyond 12 weeks.

inv-28: Minocycline ER (Solodyn/Ximino/Minolira) — ER oral minocycline indication summary

Indication summaryExtended-release oral minocycline (Solodyn, Ximino, Minolira) indicated for inflammatory lesions of non-nodular moderate to severe acne vulgaris in patients ≥12 years

Safety limitSafety not established beyond 12 weeks of use

Dosing guidanceRecommended ~1 mg/kg PO once daily for 12 weeks; max 1 mg/kg/day up to 135 mg/day

OpenPayer

Clinical Policy: Minocycline ER (Emrosi, Solodyn, Ximino, Minolira), Microspheres (Arestin), Foam (Zilxi)

Coverage and Authorization Criteria

Initial Authorization Requirements

Continuation Therapy Requirements

Step Therapy and Prior Treatments

Provider Requirements, Documentation and Alerts

Dosing, Limits and Coding Notes

Quantity and Unit-Dose Limits

Administration Setting

Clinical Background and Definitions