CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Terconazole vaginal cream 0.8% and suppository 80 mg coverage

Defines coverage and step-therapy requirements for terconazole vaginal cream 0.8% and terconazole vaginal suppository 80 mg for members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTerconazole vaginal cream 0.8% and suppository 80 mg coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2018

Next Review DateMar 1, 2025

Key ActionObtain documentation of a trial and inadequate response or intolerance to formulary miconazole (paid claim within the last 30 days) before requesting terconazole.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsmax duration

30 dayslookback

1required trials

Coverage Criteria

Initial coverage criteria

Covered when ALL of the following are met

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTerconazole vaginal cream 0.8% and suppository 80 mg coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2018

Next Review DateMar 1, 2025

Key ActionObtain documentation of a trial and inadequate response or intolerance to formulary miconazole (paid claim within the last 30 days) before requesting terconazole.

SourceLink

On This Page

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.

Referenced Formulary & Coding

Referenced formulary comparatorsNDC | mixed

miconazole vaginal cream 2% / miconazole suppository 80 mg

formulary agents used as step-therapy prerequisite (as referenced in policy text)

Lookback window for prior miconazole claim

Lookback windowAt least one paid claim for formulary miconazole vaginal cream 2% or miconazole suppository 80 mg within the last 30 days.

Required evidenceClaim/dispense history must show at least one paid miconazole claim within the 30-day lookback period.

PurposeUsed to verify prior trial of formulary miconazole before approving terconazole under step therapy.

Coverage implicationTerconazole will pay only if the 30-day lookback requirement is met (per coding logic for therapy).

Provider Actions & Requirements

Prior Authorization

Prior Authorization Requirement

Prior authorization requires documentation that the member has trialed and experienced an inadequate treatment response or intolerance to formulary miconazole vaginal cream 2% or miconazole suppository.

Required documentation: evidence of at least one claim or clinical note showing trial of formulary miconazole vaginal cream 2% or miconazole suppository within the past 30 days.
Coverage duration: 12 months once criteria met.

Step Therapy

Step Therapy Rule

Terconazole (vaginal cream 0.8% or suppository 80 mg) will be covered only after a documented trial and inadequate response or intolerance to formulary miconazole vaginal cream 2% or miconazole suppository.

Step therapy rule: at least one prior claim for formulary miconazole vaginal cream 2% or miconazole suppository is required before terconazole will pay.

Documentation Required

Documentation Guidance

Documentation submitted should demonstrate a trial of formulary miconazole vaginal cream 2% or miconazole suppository and evidence of inadequate treatment response or intolerance (e.g., clinical notes, adverse reaction documentation, or prior pharmacy claim).

Acceptable evidence: prior paid pharmacy claim within the last 30 days or clinician documentation of trial and failure/intolerance.

Denial Risk

Denial Condition

Coverage will be denied if terconazole is requested without documentation of a prior trial of and inadequate response or intolerance to formulary miconazole vaginal cream 2% or miconazole suppository.

Denial condition: absence of prior claim or clinical documentation showing trial and failure/intolerance to formulary miconazole.

Background

Terconazole (vaginal cream 0.8% and vaginal suppository 80 mg) and miconazole (vaginal cream 2% or suppository 80 mg) are topical antifungal agents commonly used to treat vulvovaginal candidiasis. This policy enforces step therapy: terconazole will only be reimbursed after documentation of a trial with and inadequate response or intolerance to formulary miconazole, with evidence of at least one paid miconazole claim within the prior 30 days. When covered, terconazole authorization is limited to a maximum duration of 12 months.

Definitions

Investigational — definition

DefinitionInvestigational use: Neighborhood does not provide coverage when a therapy is used for investigational purposes.

ScopeAll therapies are considered investigational when used at a dose or for a condition other than those recognized as medically accepted indications.

Accepted referencesMedically accepted indications are defined by standard compendia: AHFS-DI, Micromedex DrugDex, Clinical Pharmacology, Lexi-Drugs, or peer-reviewed published medical literature.