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.
No material clinical/coverage changes
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).
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