CurrentColorado Rocky Mountain Health PlansPolicy N/A

Vivjoa (oteseconazole) prior authorization for recurrent vulvovaginal candidiasis

Defines prior authorization and medical necessity criteria for coverage of Vivjoa for females with recurrent vulvovaginal candidiasis who are not of reproductive potential; applies to pharmacy benefit adjudication.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyVivjoa (oteseconazole) prior authorization for recurrent vulvovaginal candidiasis

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 1, 2025

Next Review DateAug 1, 2025

Key ActionObtain prior authorization demonstrating diagnosis of RVVC, patient is not of reproductive potential, exclusion of other causes, and failure of a 6-month weekly fluconazole maintenance trial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4 monthsauthorization duration

6 monthsfluconazole maintenance trial

not of reproductive potentialrequired patient population

2022-2025P&T reviews

Coverage criteria for Vivjoa (oteseconazole)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-01: Initial Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met

Initial approval criteria: 1) Diagnosis of recurrent vulvovaginal candidiasis; 2) Patient is not of reproductive potential (i.e., biological female who is postmenopausal or has another reason for permanent infertility such as tubal ligation, hysterectomy, or salpingo-oophorectomy); 3) Both of the following: a) other causes (including but not limited to bacterial vaginosis or trichomoniasis) have been ruled out; b) failure of a maintenance course of oral fluconazole defined as 100-mg, 150-mg, or 200-mg taken weekly for 6 months (note: for Connecticut, Kentucky, and Mississippi business a 30-day trial is sufficient); 4) Prescribed by or in consultation with an infectious disease physician or an obstetrician/gynecologist.

Authorization will be issued for 4 months

Use of Vivjoa (oteseconazole) is limited to females with recurrent vulvovaginal candidiasis (RVVC) who are not of reproductive potential. The policy defines "not of reproductive potential" as biological females who are postmenopausal or have another reason for permanent infertility (for example, tubal ligation, hysterectomy, or salpingo‑oophorectomy).

Vivjoa does not meet the coverage criteria when the patient has not failed an adequate maintenance course of fluconazole or when the patient is of reproductive potential. The required maintenance fluconazole trial is defined as weekly oral fluconazole at 100 mg, 150 mg, or 200 mg for 6 months (note: a 30‑day trial applies for CT, KY, and MS business).

Initial authorization criteria

inv-12: Initial Therapy — Initial authorization criteria

Initial authorization criteria

Initial authorization: Diagnosis of recurrent vulvovaginal candidiasis; patient is not of reproductive potential; other causes (including but not limited to bacterial vaginosis or trichomoniasis) have been ruled out; failure of a maintenance course of oral fluconazole defined as 100-mg, 150-mg, or 200-mg taken weekly for 6 months (30-day trial allowed for CT, KY, MS business); prescribed by or in consultation with an infectious disease physician or an obstetrician/gynecologist.

Authorization for 4 months

Provider requirements, documentation, and denial triggers

Prior Authorization

Prior Authorization Required

Prior authorization required. Vivjoa (oteseconazole) prior authorization will be approved only when ALL authorization criteria are met: diagnosis of recurrent vulvovaginal candidiasis; patient is not of reproductive potential; other causes ruled out; failure of a maintenance course of oral fluconazole; and prescribed by or in consultation with an Infectious Disease physician or Obstetrician/Gynecologist. Authorization will be issued for 4 months. State mandates, federal requirements, and member-specific benefits may affect coverage.

Diagnosis: recurrent vulvovaginal candidiasis required
Patient not of reproductive potential (postmenopausal or permanently infertile; e.g., tubal ligation, hysterectomy, salpingo-oophorectomy)
Other causes ruled out (e.g., bacterial vaginosis, trichomoniasis)
Failure of maintenance oral fluconazole: 100 mg, 150 mg, or 200 mg weekly for 6 months (note: CT, KY, and MS require only a 30-day trial)
Prescriber: Infectious disease physician OR Obstetrician/Gynecologist
Authorization duration: 4 months

Step Therapy

Step Therapy Note

Step therapy may apply; specific step edits are not listed in this document. UnitedHealthcare programs may permit automated approval or reauthorization based on prior claim/medication history, diagnosis codes (ICD-10), and claim logic.

Step edits may be enforced per payer program
Automated approval/re-approval may be used when prior medication/claim history supports therapy

Documentation Required

Required Documentation

Documentation must support the diagnosis of recurrent vulvovaginal candidiasis and include evidence the patient is not of reproductive potential (e.g., documentation of postmenopausal status or history of permanent infertility such as tubal ligation, hysterectomy, or salpingo‑oophorectomy). Include documentation that other causes were ruled out and records showing failure of the required fluconazole maintenance course (or 30‑day trial where applicable). Include specialist consultation or prescriber specialty when applicable.

Evidence of recurrent vulvovaginal candidiasis diagnosis (clinical notes, cultures if available)
Proof patient is not of reproductive potential (medical history, operative reports, or provider statement)
Documentation that other causes (bacterial vaginosis, trichomoniasis, etc.) were evaluated and excluded
Records showing failure of maintenance oral fluconazole (100, 150, or 200 mg weekly for 6 months) — or 30‑day trial for CT, KY, MS
Prescribing provider specialty or documentation of consultation with Infectious Disease or OB/GYN

Denial Risk

Denial Triggers

Denial may result if all authorization criteria are not met. Common denial triggers include lack of diagnosis of recurrent vulvovaginal candidiasis, patient of reproductive potential, other causes not ruled out, insufficient documentation of fluconazole trial/failure, or absence of required specialist prescriber/consultation.

No documented diagnosis of recurrent vulvovaginal candidiasis
Patient documented as of reproductive potential
Other causes (e.g., BV, trichomoniasis) not excluded
No documentation of required fluconazole maintenance trial (or applicable 30‑day trial)
Prescriber is not an Infectious Disease physician or OB/GYN and no documented consultation

Step	Note
1	Step therapy may be in place; specific step edits are not provided in this document.
	Coverage decisions may also be made via automated approval based on previous claim/medication history, diagnosis codes, or claim logic per program rules.

Definitions and clinical terms

Not of reproductive potential

DefinitionPersons who are biological females who are postmenopausal or have another reason for permanent infertility (e.g., tubal ligation, hysterectomy, salpingo-oophorectomy)

Policy scopeVivjoa is indicated for females with a history of RVVC who are not of reproductive potential

Documentation examplesMedical record evidence such as menopausal status, surgical sterilization, or other permanent infertility documentation must be provided

Exclusion implicationPatients of reproductive potential are excluded from coverage under this policy

Recurrent vulvovaginal candidiasis (RVVC)

DefinitionRepeated episodes of vulvovaginal candidiasis (recurrent vulvovaginal candidiasis, RVVC)

Applicable populationPolicy applies to females with a history of RVVC who are not of reproductive potential

Requirement for authorizationDiagnosis of RVVC must be documented in the medical record to meet coverage criteria

Other causesOther causes of vaginitis (e.g., bacterial vaginosis, trichomoniasis) must be ruled out per policy

OpenPayer

Vivjoa (oteseconazole) prior authorization for recurrent vulvovaginal candidiasis

Coverage criteria for Vivjoa (oteseconazole)

Initial authorization criteria

Reauthorization / continuation criteria

Key coding and trial duration

Provider requirements, documentation, and denial triggers

Step therapy rules

Definitions and clinical terms

Background