CurrentNeighborhood Health Plan of Rhode IslandPolicy 4312-HJ 03-2023

Topical Metronidazole (cream/gel/lotion) — Prior Authorization and Quantity Limits

This policy governs prior authorization and quantity limits for topical metronidazole products (cream, gel, lotion) for treatment of rosacea for members of Neighborhood Health Plan of Rhode Island via CVS Caremark criteria.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTopical Metronidazole (cream/gel/lotion) — Prior Authorization and Quantity Limits

Policy CodePolicy 4312-HJ 03-2023

Change TypeNo material changes

Effective DateMar 20, 2023

Next Review DateN/A

Key ActionObtain prior authorization for topical metronidazole prescribed for rosacea and ensure it is not intended for use in a footbath.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 gmTypical 1-month limit per product

180 gmTypical 3-month limit per product

MultipleFormulations listed

Coverage Criteria for Topical Metronidazole

Coverage with Prior Authorization

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Product List and Quantity Limits

Listed topical metronidazole productsmixed

metronidazole 0.75% cream	MetroCream (metronidazole topical cream) 0.75% — indicated for inflammatory papules and pustules of rosacea
metronidazole 1% cream	Noritate (metronidazole cream) 1% — indicated for inflammatory lesions and erythema of rosacea
metronidazole gel 1%	MetroGel (metronidazole gel 1%) — indicated for inflammatory lesions of rosacea
metronidazole gel 0.75%	Metronidazole gel 0.75% — indicated for inflammatory papules and pustules of rosacea
metronidazole lotion 0.75%	MetroLotion (metronidazole lotion 0.75%) — indicated for inflammatory papules and pustules of rosacea

Quantity limits

30-day (1 month) quantity limit60 gm per 25 days (used for a 30-day fill period)

90-day (3 month) quantity limit180 gm per 75 days (used for a 90-day fill period)

Accumulation ruleLimits accumulate across all listed topical metronidazole drugs and strengths up to the highest quantity listed unless the limit is coded as a daily dose.

Pharmacy dispensing discretionDispensing pharmacies may fill package sizes up to the quantity limits; day supply may be adjusted per package size.

What Providers Must Do / Authorization Details

Prior Authorization

Prior Authorization Required

Prior authorization is required. The requested drug will be covered with prior authorization when prescribed for the treatment of rosacea and not used in excluded ways.

PA required for rosacea treatment only
Not covered if intended for use in a footbath
Quantity limits apply (see quantity limit handling callout)

Denial Risk

Coverage Prerequisites

Provider must ensure the request meets coverage prerequisites. Requests will be denied if the drug is not prescribed for rosacea or if it is intended for use in a footbath.

Denial risk if diagnosis is not rosacea
Denial risk if documentation indicates footbath use

Billing Rule

Quantity Limit Handling

Quantity limits accumulate across listed metronidazole topical products and strengths up to the highest applicable limit. Pharmacies may dispense package sizes up to the quantity limits; day-supply calculations use 25 days for a 30-day fill and 75 days for a 90-day fill to allow for refill processing.

Limits accumulate across all metronidazole topical formulations and strengths
1-month limit example: 60 g (uses 25-day day-supply for a 30-day fill)
3-month limit example: 180 g (uses 75-day day-supply for a 90-day fill)
Pharmacy may dispense package sizes that result in filling quantities and day supply less than the nominal limits

Background

Topical metronidazole is available in cream, gel, and lotion formulations and is used for the topical treatment of inflammatory lesions associated with rosacea, including papules and pustules and associated erythema. Multiple branded and generic topical metronidazole products and concentrations are used for this indication.

Under this policy, these topical metronidazole formulations are covered only when prescribed for rosacea and when they are not being used in a footbath. Quantity limits apply per the coding section.

Definitions

Topical metronidazole (cream/gel/lotion) — definitions and typical indications

DefinitionTopical metronidazole (cream, gel, lotion) are topical antibiotics indicated for the topical treatment of inflammatory papules, pustules, and other inflammatory lesions of rosacea (including erythema for some formulations).

Typical formulations listedCream (metronidazole 0.75%, Noritate 1%), gel (0.75% and 1%), and lotion (0.75%) are included among covered topical products.

IndicationsUsed for treatment of inflammatory papules, pustules, and inflammatory lesions of rosacea; some products (e.g., Noritate) also list erythema.

Product examplesMetroCream (metronidazole cream 0.75%), MetroGel (metronidazole gel 1%), MetroLotion (metronidazole lotion 0.75%), metronidazole gel 0.75%, Noritate (metronidazole cream 1%).