CurrentMass General Brigham Health PlanPolicy N/A

Topical Antifungal Agents (Pharmacy Benefit) Coverage Criteria

Defines coverage, step therapy, prior authorization, and quantity/coverage limits for topical antifungal medications for Mass General Brigham Health Plan members under the pharmacy benefit.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTopical Antifungal Agents (Pharmacy Benefit) Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative review / format switch

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization when the member has not filled a ≥7-day supply of a generic topical antifungal in the past 120 days or document failure/intolerance/contraindication.

SourceLink

POLICY UPDATE CHANGES

Policy was reviewed and switched from SGM to Custom effective 01/01/2024.

3 monthsinitial approval

7 daysminimum fill

120 dayslookback window

12+agents listed

Coverage Criteria for Topical Antifungal Agents

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Second-line topical antifungal coverage criteria

Coverage for second-line topical antifungal agents is permitted when one of the following is met:

Step therapy pass: Member has filled at least a 7-day supply of a generic topical antifungal within the past 120 days (claim will adjudicate at point-of-sale)>=7-day supply within 120 days

If not met, claim denies and PA required

Failure/intolerance/contraindication: Member experienced inadequate treatment response to a generic topical antifungal agent, intolerance to a generic topical antifungal agent, or has a contraindication to a generic topical antifungal agentN/A

Provider must document reason in PA

Continuation for new-to-plan members: Member is new to the plan and currently receiving the requested medication (excludes samples and manufacturer patient assistance program supply)Current treatment documented

Authorization may be granted to avoid interruption of therapy

The requested drug will not be used in a footbath.

Prior Authorization, Documentation, and Point-of-Sale Rules

Denial Risk

Point-of-Sale Denial for Unmet Step Therapy

Prescriptions that do not meet the initial step-therapy requirements will deny at point-of-sale with a message indicating that prior authorization (PA) is required. Submit a PA request for members who do not meet the initial step-therapy criteria to avoid claim denial at the pharmacy.

Point-of-sale denial message: PA required when initial step therapy criteria are unmet
If denied at point-of-sale, submit PA to PA unit for evaluation

Prior Authorization

Prior Authorization Required — Exceptions and Acceptance Criteria

Prior authorization is required when the member does not meet initial step-therapy criteria. Authorization may be granted if the member had an inadequate response or intolerance to a required first-line agent, has a contraindication to first-line therapy, or is new to the plan and currently receiving the requested medication (exclusions apply).

PA may be granted if member had inadequate response or intolerance to a generic topical antifungal
PA may be granted for members new to the plan who are currently receiving the requested medication (excludes samples and manufacturer patient assistance program supplies)
Requested drug must not be used in a footbath

Step Therapy

Initial Step-Therapy Requirements

Initial step-therapy requirements: first-line agents are covered without PA. Second-line agents require evidence of a prior fill of at least a 7-day supply of a generic topical antifungal within the past 120 days or an approved PA documenting inadequate response, intolerance, or contraindication to first-line therapy.

First-line agents: covered without prior authorization
Second-line agents (examples include econazole, sertaconazole, sulconazole nitrate, ketoconazole products, ciclopirox, clotrimazole/betamethasone, luliconazole, butenafine, naftifine, oxiconazole, miconazole combinations): require ≥7-day generic topical antifungal fill within past 120 days or PA
Initial approvals are granted for 3 months

Documentation Required

Documentation to Support Prior Authorization

Documentation to support PA: include evidence of prior fill(s), clinical rationale for inadequate response or intolerance, contraindications to first-line therapy, and current medication history if member is new to plan. Exclude documentation of samples or manufacturer patient assistance program supplies as proof of prior use.

Evidence of a ≥7-day fill of a generic topical antifungal within past 120 days (prescription benefit)
Clinical notes documenting inadequate response or intolerance to first-line therapy, or contraindication
Medication history for members new to the plan (exclude samples and manufacturer patient assistance program supplies)

Initial Therapy Placement

Initial therapy placement

First-line agents are covered without prior authorization; second-line agents are listed below and subject to step therapy.

First-line coverage: Agents listed as first-line in the policy will adjudicate automatically at point-of-sale without prior authorizationN/A

First-line list referenced in policy

Second-line listing: Specific topical antifungals enumerated in policy are considered second-line and require evidence of prior generic topical antifungal use (>=7-day supply within 120 days) or prior authorization documenting failure, intolerance, or contraindication>=7-day supply within 120 days

Second-line products include econazole, sertaconazole, sulconazole nitrate, ketoconazole formulations, ciclopirox, clotrimazole/betamethasone, luliconazole, butenafine, naftifine, oxiconazole, miconazole/zinc oxide/white petrolatum

Step Therapy Operational Rules

Requirement	Evidence needed	Notes
Prior fill (step therapy pass)	>= 7‑day supply of a generic topical antifungal within the past 120 days	If met, the second‑line topical will adjudicate at point‑of‑sale; if not met, claim rejects and PA is required
Prior authorization documenting failure/intolerance/contraindication	Provider documentation that member had inadequate treatment response, intolerance, or a contraindication to a generic topical antifungal	PA will be evaluated by the prior authorization unit; authorization may be granted to avoid interruption of therapy
Continuation for members new to plan	Documentation that member is currently receiving the requested medication (excludes samples and manufacturer patient assistance program supplies)	Authorization may be granted to support continuity of care

Policy Summary

PayerMass General Brigham Health Plan

PolicyTopical Antifungal Agents (Pharmacy Benefit) Coverage Criteria

Policy CodePolicy N/A

Change TypeAdministrative review / format switch

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization when the member has not filled a ≥7-day supply of a generic topical antifungal in the past 120 days or document failure/intolerance/contraindication.

SourceLink

On This Page

OpenPayer

Topical Antifungal Agents (Pharmacy Benefit) Coverage Criteria

Coverage Criteria for Topical Antifungal Agents

Plan Identifiers and Coding Rules

Prior Authorization, Documentation, and Point-of-Sale Rules

Initial Therapy Placement

Continuation Therapy

Step Therapy Operational Rules

Quantity and Duration Limits

Definitions

Background