CurrentColorado Rocky Mountain Health PlansPolicy N/A

Topical antifungal prior authorization (nystatin/clotrimazole agents)

Form-based prior authorization requirements for topical antifungal agents (nystatin and clotrimazole products) used for beneficiaries, specifying prescriber, beneficiary, and trial/failure and age information. Affects prescribers requesting coverage from the payer.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyTopical antifungal prior authorization (nystatin/clotrimazole agents)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form including prescriber signature and document failure of at least two different prescription topical products from the specified list within the past 60 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥4 wksmin age queried

2prior trials required

50 gmquantity limit

30/60dtherapy length options

Coverage Criteria

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Initial authorization

Covered when ALL of the following are met:

Topical antifungal PA criteria: 1) Patient is at least four weeks of age; 2) Prescriber completes beneficiary, prescriber, and drug information fields and signs the form (prescriber signature mandatory); 3) Patient has tried and failed at least 2 different prescription products from the list (nystatin cream, nystatin ointment, nystatin/triamcinolone cream, nystatin/triamcinolone ointment, clotrimazole cream) within the past 60 days; 4) Requested quantity does not exceed the quantity limit of 50 gm per 60 days.

Length of therapy must be indicated (up to 30 or 60 days).

Requests for topical antifungal prior authorization are not eligible for patients younger than 4 weeks of age. The form explicitly asks “Is the recipient at least four weeks of age?” and requires the prescriber to confirm that the patient meets this minimum age before approval is considered.

Coverage requires documentation that the patient has tried and failed at least two different prescription products from the specified list within the prior 60 days. The form asks whether the patient “has tried and failed on at least 2 different prescription products from this list within the past 60 days” and provides space to list the products failed; requests without this documentation are considered not medically necessary.

Coding and Limits

Minimum patient age

Minimum patient ageAt least 4 weeks (recipient must be ≥4 weeks old)

Exclusion for younger patientsRequests for patients younger than four weeks of age are not eligible per the form

Age confirmation fieldForm asks: 'Is the recipient at least four weeks of age?' with Yes/No checkboxes

Quantity limit

Quantity limit50 gm per 60 days

Applies toTopical antifungal preparations listed on the form

DocumentationQuantity limit noted on form under clinical information

Provider Actions and Requirements

Prior Authorization

Form completion and required fields

Prior authorization requires completion of the specialty drug prior authorization form with all requested fields and documentation of prior trials before the request will be approved.

Complete the prior authorization form including drug name, strength, quantity per 30 days, and length of therapy selection (up to 30 or 60 days).
Include beneficiary information: beneficiary last name, first name, beneficiary ID #, date of birth, and gender.
Include prescriber information: prescribing provider NPI # and requester contact information (name, phone #, ext.).

Documentation Required

Required form fields and signature

The prescriber’s signature and date are mandatory. The form must include patient age and the clinical documentation fields showing prior product trials.

Signature of Prescriber (mandatory) and Date.
Patient age (beneficiary date of birth) must be documented.
Clinical information fields showing products tried and failed and any supporting notes.

Step Therapy

Step therapy requirement

Step therapy: patient must have tried and failed at least two different prescription topical products from the specified list within the past 60 days prior to approval.

Required prior trials (at least 2 different products within past 60 days): nystatin cream, nystatin ointment, nystatin/triamcinolone cream, nystatin/triamcinolone ointment, or clotrimazole cream.
If prior trials are not documented, the request may be denied or returned for additional information.

Denial Risk

Prior trials and denial risk

Failure to document at least two different prescription product trials from the specified list within the past 60 days may result in denial of the prior authorization request.

Quantity limit note: a quantity limit of 50 gm per 60 days applies.
Ensure the form lists the specific products that were tried and dates or duration to support the 60-day window.

Initial Therapy

Initial therapy

Initial authorization requires documented prior topical therapy trials and patient eligibility

Initial topical antifungal authorization: Patient is at least 4 weeks old; documentation of failure of at least two different prescription products from the specified list within the past 60 days (nystatin cream; nystatin ointment; nystatin/triamcinolone cream; nystatin/triamcinolone ointment; clotrimazole cream); prescriber-signed form including drug name, strength, quantity per 30 days, and length of therapy selection.

Quantity limited to 50 gm per 60 days.

Step Therapy Requirements

Requirement	Details
Patient age
Recipient is at least four weeks of age (requests for patients younger than 4 weeks are excluded).
Prior trials
Patient has tried and failed at least 2 different prescription products from the following list within the past 60 days: nystatin cream, nystatin ointment, nystatin/triamcinolone cream, nystatin/triamcinolone ointment, or clotrimazole cream. Provider must list products failed on the form.
Form completion and signature
Prescriber must complete beneficiary, prescriber, and drug information on the form, indicate length of therapy, and provide prescriber signature and date (signature mandatory).
Quantity limit
Requested quantity must not exceed 50 gm per 60 days.

Background

This prior authorization form is used to request coverage for topical antifungal therapies (prescription nystatin and clotrimazole preparations and combinations). It collects basic beneficiary and prescriber demographics, the drug name/strength/quantity and length of therapy, and clinical confirmation items including patient age and prior topical product failures. The form also contains a mandatory prescriber signature and notes a quantity limit of 50 gm per 60 days.