CurrentNeighborhood Health Plan of Rhode IslandPolicy 5466-€ Policy 10-2022

Xepi (ozenoxacin) topical for impetigo

Defines prior authorization and quantity limit criteria for coverage of Xepi (ozenoxacin) topical for treatment of impetigo in members aged 2 months and older, including required prior trial/intolerance/contraindication to topical mupirocin and dispensing quantity limits.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyXepi (ozenoxacin) topical for impetigo

Policy CodePolicy 5466-€ Policy 10-2022

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrior authorization is required and the request must document diagnosis of impetigo due to S. aureus or S. pyogenes, patient age (>=2 months), and evidence of inadequate response, intolerance, or contraindication to topical mupirocin.

POLICY UPDATE CHANGES

No material clinical/coverage changes

1Indication covered (impetigo)

30 gQuantity limit

>=2 moMinimum age

Coverage Summary

Policy covers Xepi (ozenoxacin) topical for the treatment of impetigo due to Staphylococcus aureus or Streptococcus pyogenes in patients aged >= 2 months when prior authorization criteria are met. Coverage requires documentation that the patient has had an inadequate treatment response to a trial of topical mupirocin, or has an intolerance or contraindication that would prohibit a trial of topical mupirocin. The product must not be used in a footbath. Quantity limit: 30 grams per 25 days; dispense one-month supplies only (mail-order limit equals retail limit; do not fill 3-month supplies).

Initial Therapy Criteria (Prior Authorization)

Initial Prior Authorization / Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

Indication: Requested drug is being prescribed for the topical treatment of impetigo due to Staphylococcus aureus or Streptococcus pyogenes
Age: Patient is 2 months of age or older>= 2 months
One of the following regarding mupirocin
- Inadequate response: Patient has experienced an inadequate treatment response to a trial of topical mupirocin
  Clinical failure to resolve impetigo following a trial of topical mupirocin (as assessed by prescribing clinician).
- Intolerance: Patient has experienced an intolerance to topical mupirocin
- Contraindication: Patient has a contraindication that would prohibit a trial of topical mupirocin
Use limitation: Requested drug is not being used in a footbath

ref

Provider Actions & Billing Rules

Prior Authorization

Prior authorization required

Prior authorization is required for coverage. The request must document diagnosis of impetigo due to Staphylococcus aureus or Streptococcus pyogenes, patient age (>=2 months), and evidence of an inadequate response, intolerance, or contraindication to topical mupirocin.

Billing Rule

Quantity limit / dispensing frequency

Dispense one-month supplies only; mail-order limit equals retail limit; do not fill 3-month supplies. Quantity limit: 30 grams per 25 days.

Documentation Required

Document mupirocin trial/intolerance/contraindication

Provider must document either prior inadequate response to topical mupirocin, intolerance to topical mupirocin, or a contraindication that prohibits a mupirocin trial. (Inadequate treatment response = clinical failure to resolve impetigo following a trial of topical mupirocin as assessed by the prescribing clinician.)

Background

Background: Xepi (ozenoxacin) is FDA-approved for topical treatment of impetigo due to Staphylococcus aureus or Streptococcus pyogenes in patients 2 months of age and older. This policy aligns coverage to that indication and requires a prior trial of topical mupirocin or documentation justifying avoidance (inadequate response, intolerance, or contraindication).

Policy number: 5466-€ Policy 10-2022. Last review date: 2022-09-09. Status: CURRENT.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyXepi (ozenoxacin) topical for impetigo

Policy CodePolicy 5466-€ Policy 10-2022

Change TypeNo material change

Effective Date

Next Review Date

On This Page

OpenPayer

Xepi (ozenoxacin) topical for impetigo

Coverage Summary

Initial Therapy Criteria (Prior Authorization)

Provider Actions & Billing Rules

Applicable Codes

Clinical Evidence & References

Background

Definitions

Revision History