CurrentNeighborhood Health Plan of Rhode IslandPolicy 5466-C

ozenoxacin (Xepi) topical — coverage criteria for impetigo

Policy governs prior authorization and quantity limits for Xepi (ozenoxacin) topical when prescribed for impetigo due to Staphylococcus aureus or Streptococcus pyogenes, affecting prescribers and covered members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policyozenoxacin (Xepi) topical — coverage criteria for impetigo

Policy CodePolicy 5466-C

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document either a trial and inadequate response to topical mupirocin or intolerance/contraindication to mupirocin.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 monthsminimum patient age

30 gquantity limit

1 monthfill interval

Coverage Criteria for Xepi (ozenoxacin) Topical

Initial Authorization

Covered when ALL of the following criteria are met:

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

Policyozenoxacin (Xepi) topical — coverage criteria for impetigo

Policy CodePolicy 5466-C

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document either a trial and inadequate response to topical mupirocin or intolerance/contraindication to mupirocin.

SourceLink

On This Page

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Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage of the requested topical agent for impetigo.

Covered when prescribed for topical treatment of impetigo due to Staphylococcus aureus or Streptococcus pyogenes.
Patient must be ≥ 2 months of age.
Request will be reviewed against the coverage criteria (diagnosis and prior therapy).

Denial Risk

Triggers for Denial

Requests may be denied if required conditions are not met.

Patient is < 2 months of age.
Request is for use in a footbath.
Coverage criteria not met (e.g., diagnosis or age not supported).

Step Therapy

Step Therapy Requirement

A step-therapy requirement applies before use of the requested agent.

Trial of topical mupirocin with inadequate response is required OR documentation of intolerance or contraindication to topical mupirocin must be provided.

OpenPayer

ozenoxacin (Xepi) topical — coverage criteria for impetigo

Coverage Criteria for Xepi (ozenoxacin) Topical

Provider Actions, Prior Authorization, and Documentation

Background on Ozenoxacin (Xepi)

Definitions and FDA-Approved Indication