CurrentNeighborhood Health Plan of Rhode IslandPolicy 2940-HJ 10-2022

Topical mupirocin (mupirocin calcium cream and Centany ointment) prior authorization and quantity limits

Defines coverage, prior authorization, and quantity limits for topical mupirocin products (mupirocin calcium cream and Centany ointment) for members of Neighborhood Health Plan of Rhode Island (implemented via CVS Caremark criteria). Affects providers prescribing these topical antimicrobials and pharmacy benefit adjudication.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTopical mupirocin prior authorization and quantity limits

Policy CodePolicy 2940-HJ 10-2022

Change TypeNo material changes

Effective DateOct 20, 2022

Next Review Date

Key ActionObtain prior authorization when the requested quantity exceeds the plan's initial 30 gram per ~25 day limit and document the clinical indication and quantity needed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 gmper-fill max

25 daysfill duration

60 gmalternate limit

PA requiredover limit

Coverage Criteria

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PA coverage criteria by product and indication

Covered with prior authorization when ALL of the following criteria are met for the specified product:

Mupirocin calcium cream

Indications for cream: Traumatic skin lesions due to susceptible isolates of Staphylococcus aureus or Streptococcus pyogenes OR superficial bacterial skin infections
Supports FDA/compendial indications

Mupirocin ointment (Centany)

Indications for ointment: Impetigo due to Staphylococcus aureus or Streptococcus pyogenes OR superficial bacterial skin infections OR prophylaxis of catheter exit-site infections
Supports FDA/compendial indications

Exclusions and quantity: Requested drug is not being used in a footbath AND when a body surface area to be treated requires more than 30 grams in a one-month period30 grams per month

Quantity limits apply; requests exceeding initial limits require prior authorization

The request must not be for use in a footbath. This is an explicit exclusion within the coverage criteria: the requested drug must not be used in a footbath. Requests indicating footbath use are outside the covered indications and may be denied.

Use of the requested drug in a footbath is explicitly not covered. The policy states that the requested drug is not being used in a footbath, and any request that documents footbath use is not allowed under this coverage policy.

Coding and Quantity Limits

Covered topical mupirocin productsmixedCovered

brand/generic

Mupirocin calcium cream; Centany (mupirocin) ointment

Per-fill quantity limits

Per-fill quantity limit (standard)30 grams per ~25 day period (intent: one-month fill) for each product (mupirocin calcium cream and Centany ointment)

Rationale for 25-day duration25 days is used to represent a 30-day fill period to allow time for refill processing; mail order limit equals retail limit

Alternate summed limit notedDocument also cites an alternate value of 60 grams per 25 days in one location

Filling intentPrescriptions intended to be filled one month at a time; no 3-month supplies

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for coverage of mupirocin calcium cream and ointment when the request exceeds the plan's initial quantity limit. If a patient requests more than the initial quantity limit the claim will reject with a message indicating that a prior authorization is required; the prior authorization criteria will then be applied to requests submitted for evaluation to the PA unit.

Applies to mupirocin calcium cream and mupirocin ointment
Initial quantity intended as a one-month supply; no 3-month fills

Denial Risk

Quantity Over Limit Triggers Denial/Review

Requests exceeding the plan's initial quantity limit will reject at claim adjudication and require prior authorization review. Providers should submit clinical justification and documentation to the PA unit for requests over the limit.

Claim rejection triggers PA review when quantity > initial limit
PA evaluation applies CVS Caremark post-PA policy 2940-HJ 10-2022

Documentation Required

Clinical Indication and Quantity Justification

Documentation must support the indicated diagnosis and justify the requested quantity. Appropriate indications include impetigo due to Staphylococcus aureus or Streptococcus pyogenes, superficial bacterial skin infections, or prophylaxis of catheter exit-site infections. For requests exceeding a one-month quantity, documentation should demonstrate that the treated body surface area requires more than 30 grams in a one-month period.

Supported indications: impetigo (S. aureus or S. pyogenes), superficial bacterial skin infections, catheter exit-site prophylaxis
Quantity justification: >30 grams per month based on body surface area treated
Include clinical notes specifying diagnosis, treated area size, and intended duration

Denial Risk

Footbath Use Exclusion

Use of mupirocin in a footbath is explicitly excluded. Requests indicating footbath use are not allowed and may be denied.

Footbath application is an explicit exclusion — do not submit PA requests for this use

Background

Mupirocin products covered by this policy are topical antibiotics intended for localized skin infections. The document’s coverage criteria include treatment of impetigo due to Staphylococcus aureus or Streptococcus pyogenes, superficial bacterial skin infections, and prophylaxis of catheter exit-site infections where applicable. The policy also specifies quantity considerations (e.g., when more than 30 grams in a one‑month period are required) and excludes uses such as footbaths.

Drug Indications / Definitions

Mupirocin calcium cream — approved indication

Indication (cream)Treatment of secondarily infected traumatic skin lesions (up to 10 cm in length or ~100 cm in area) due to susceptible isolates of Staphylococcus aureus and Streptococcus pyogenes

Typical pathogensStaphylococcus aureus (S. aureus) and Streptococcus pyogenes (S. pyogenes)

Size limitationLesions up to 10 cm in length (area described in source)

Regulatory sourceFDA‑approved indication for mupirocin calcium cream

Centany (mupirocin) ointment — approved and compendial indications

Indication (ointment)Topical treatment of impetigo due to Staphylococcus aureus and Streptococcus pyogenes

Compendial/other usesIncludes compendial uses such as prophylaxis of catheter exit-site infections and other superficial bacterial skin infections (as listed in product literature)