Centany (mupirocin) ointment — CareFirst (Caremark)

superficial bacterial skin infections

Initial criteria

The requested drug is NOT being used in a footbath
The requested drug is being prescribed to treat a body surface area that requires more than 30 grams in a one-month period
The patient meets ONE of the following:
If the request is for mupirocin calcium cream, the drug is being prescribed for ANY of the following: treatment of secondarily infected traumatic skin lesions due to susceptible isolates of Staphylococcus aureus or Streptococcus pyogenes; superficial bacterial skin infections
If the request is for mupirocin ointment (Centany), the drug is being prescribed for ANY of the following: impetigo due to Staphylococcus aureus or Streptococcus pyogenes; superficial bacterial skin infections; prophylaxis of catheter exit-site infections

1 month