CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

XEPI (ozenoxacin) prior authorization for impetigo

Defines prior authorization and quantity limits for topical Xepi (ozenoxacin) used to treat impetigo in patients aged 2 months and older for members of Neighborhood Health Plan of Rhode Island (administered via CVS Caremark criteria).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyXEPI (ozenoxacin) prior authorization for impetigo

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2022

Next Review DateN/A

Key ActionObtain prior authorization and document diagnosis, patient age (≥2 months), and a trial/intolerance/contraindication to topical mupirocin; limit dispensing to 30 g per 25 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥2 moMinimum patient age for coverage

30 g/25 dQuantity limit

Prior authAuthorization type

ImpetigoCovered indication

Coverage Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Indication: Requested drug is prescribed for the topical treatment of impetigo due to Staphylococcus aureus or Streptococcus pyogenespatient age >= 2 months

FDA-approved indication

Mupirocin trial requirement: Patient has experienced an inadequate treatment response to a trial of topical mupirocin OR the patient has experienced an intolerance to topical mupirocin OR the patient has a contraindication that would prohibit a trial of topical mupirocindocumented trial, intolerance, or contraindication

Step therapy requirement

Dispensing and quantity limits: Drug is for short-term acute use; prescriptions should be filled one month at a time (no 3-month supplies).30 grams per 25 days

Applies to retail and mail order

Exclusion: Requested drug is not being used in a footbath

Coding and Limits

inv-03: Quantity limit — 30 grams per 25 days

Quantity limit30 grams per 25 days

Fill intentPrescriptions intended to be filled one month at a time (no 3-month supplies)

Applies toRetail and mail order (mail limit same as retail)

inv-04: Minimum age — ≥ 2 months

Minimum patient age≥ 2 months

PopulationAdult and pediatric patients 2 months of age and older

Coverage criterion noteRequested drug must be for topical treatment of impetigo in patients aged ≥2 months

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required for Xepi (ozenoxacin). Quantity limit: 30 grams per 25 days. Prescriptions should be filled one month at a time (no 3-month supplies).

Prior authorization with quantity limit: 30 grams per 25 days
Fill intent: one month at a time; no 3-month supplies

Step Therapy

Step Therapy Requirement

A trial of topical mupirocin is required prior to approval unless there is documented inadequate response, intolerance, or a contraindication to mupirocin.

Step therapy: topical mupirocin trial required unless inadequate response/intolerance/contraindication

Documentation Required

Documentation Requirements

Document the diagnosis of impetigo caused by Staphylococcus aureus or Streptococcus pyogenes and the patient’s age (must be 2 months or older). Also document any trial of topical mupirocin, or rationale for intolerance/contraindication if mupirocin was not tried.

Required documentation: diagnosis specifying impetigo due to S. aureus or S. pyogenes
Patient age documented (>= 2 months)
Documentation of mupirocin trial and inadequate response OR documentation of intolerance/contraindication

Denial Risk

Denial Risk Conditions

Requests will be denied if the indication is not impetigo due to S. aureus or S. pyogenes, if the patient is younger than 2 months, or if required documentation (diagnosis, age, mupirocin trial or intolerance/contraindication) is missing.

Denial risk if: indication is not impetigo due to S. aureus or S. pyogenes
Denial risk if: patient is younger than 2 months
Denial risk if: missing documentation of diagnosis, age, or mupirocin trial/intolerance/contraindication

Background

Impetigo is a superficial bacterial skin infection most commonly caused by Staphylococcus aureus or Streptococcus pyogenes. Xepi (ozenoxacin) is a topical antibiotic indicated for this infection in patients aged ≥ 2 months. Coverage requires documentation that the diagnosis is impetigo and that a trial of topical mupirocin has produced an inadequate response or that the patient has an intolerance or a contraindication to mupirocin. Prescriptions are intended to be filled one month at a time; quantity limit: 30 grams per 25 days, and no 3-month supplies should be dispensed.

Definitions

inv-10: Xepi (ozenoxacin) — indication and age statement

IndicationTopical treatment of impetigo due to Staphylococcus aureus or Streptococcus pyogenes

Age statementIndicated in patients 2 months of age and older

DrugXepi (ozenoxacin) — topical antibiotic

inv-11: Quantity limit / dispensing intent — short-term acute use; fill one month at a time (30 g per 25 days), includes mail order

Dispensing intentDrug is for short-term acute use; prescriptions should be filled one month at a time

Mail orderMail limit is the same as retail; no 3-month supplies

Quantity limit linkageEnforced as 30 grams per 25 days