Table 41: Antibiotics - Topical
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Drug Category: Dermatological
Medication Class/Individual Agents: Antibiotics
I. Prior-Authorization Requirements
Topical Antibacterials |
Clinical Notes |
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Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.
Warnings and Precautions:
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Vaginal Antibiotics |
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# | This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent. |
* | The generic OTC and, if any, generic prescription versions of the drug are payable under MassHealth without prior authorization. |
II. Therapeutic Uses
FDA-approved, for example:
- Bacterial vaginosis - Cleocin Vaginal Ovule, Clindesse, Nuvessa
- Treatment of impetigo or infection - mupirocin cream
- Eradication/prophylaxis of nasal colonization with methicillin-resistant Staphylococcusaureus (MRSA) in adult patients and health care workers to reduce the risk of infection during an institutional outbreak - Bactroban nasal ointment
Note: The above list may not include all FDA-approved indications.
III. Evaluation Criteria for Approval
- All PA requests must include clinical diagnosis, drug name, dose, and frequency.
- A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
- For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
- Additional criteria may apply, depending upon the member’s condition and requested medication (see below).
Bactroban nasal ointment for eradication/prophylaxis of nasal MRSA colonization in adult patients and health care workers to reduce the risk of infection during an institutional outbreak
- Documentation of the following is required:
- an appropriate diagnosis; and
- request is for a quantity of ≤ 10 grams for 5 days.
Cleocin Vaginal Ovule, Clindesse, and Nuvessa
- Documentation of the following is required:
- an appropriate diagnosis; and
- if the request is for Nuvessa, the member is ≥ 18 years of age; and
- an inadequate response, adverse reaction, or contraindication to oral metronidazole tablets or metronidazole 0.75% gel; and
- an inadequate response, adverse reaction, or contraindication to clindamycin 2% vaginal cream; and
- appropriate dosing.
mupirocin cream for impetigo or infected traumatic lesions
Documentation of the following is required:
- an appropriate diagnosis; and
- medical records documenting an inadequate response, adverse reaction, or contraindication to mupirocin ointment.
mupirocin powder
- Documentation of all the following is required:
- appropriate diagnosis; and
- clinical rationale why other commercially available alternatives cannot be used.
Original Effective Date: 07/2005
Last Revised Date: 08/2019
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Last updated 01/11/21