CurrentUnitedHealthcarePolicy 2025 P 1335-5

Topical Products - NJ & NY - Prior Authorization/Notification - UnitedHealthcare Commercial Plansopen_in_new

Defines prior authorization/notification clinical criteria for topical medications for UnitedHealthcare Commercial Plans in New Jersey and New York, including acceptable indications, dosing support, quantity appropriateness, documentation requirements, and authorization duration.

Policy Summary

PayerUnitedHealthcare

PolicyTopical Products - NJ & NY - Prior Authorization/Notification - UnitedHealthcare Commercial Plansopen_in_new

Policy CodePolicy 2025 P 1335-5

Change TypeAnnual review — no clinical changes

Effective DateJun 1, 2025

Next Review Date

Key ActionTopical products meeting the internal dollar threshold require prior authorization/notification and must meet the policy criteria; document body surface area and dosing instructions when requesting authorization.

SourceLink

POLICY UPDATE CHANGES

Annual review completed 3/2025 with no changes to clinical policy statements.

Effective date set to 6/1/2025 per program header.

12 monthsAuthorization Duration

4Accepted Compendia Listed

1Program Number

Coverage Summary

This policy defines prior authorization/notification clinical criteria for topical medications for UnitedHealthcare Commercial Plans in New Jersey and New York. It is administered by UnitedHealthcare Pharmacy Clinical Programs (Program Number 2025 P 1335-5) and becomes effective 6/1/2025. Topical products that meet an internal dollar threshold require prior authorization and, if approved, authorization will be issued for 12 months.

The purpose is to ensure coverage only when the requested topical medication meets the stated clinical criteria regarding indication, dosing, and quantity appropriateness and when required documentation (including body surface area and dosing instructions) is provided. State mandates, federal requirements, and member-specific benefit plans may further affect coverage.

Key Policy Facts

Authorization Duration12 months

Accepted Compendia Listed4 (AHFS; Micromedex/DrugDex; Elsevier Gold Standards Clinical Pharmacology; NCCN Drugs & Biologics)

Program Number1

Policy Number2025 P 1335-5

Effective Date2025-06-01

Last Review2025-03-01

Medical Necessity / Prior Authorization Criteria

Covered when ALL of the following are met:

ALL of the following

Indication supported by
- The requested medication is being used for an indication supported by the FDA approved labeling, peer-reviewed literature, or accepted standard of medical practice.
- The indication for the medication is supported by one of the following compendia: American Hospital Formulary Service (AHFS) Compendia; Thomson Reuters (Healthcare) Micromedex/DrugDex (not Drug Points) Compendium; Elsevier Gold Standards Clinical Pharmacology Compendium; National Comprehensive Cancer Network Drugs and Biologics Compendium.
Dose and duration supported by
- The dose and duration of treatment is supported by the FDA approved labeling, peer-reviewed literature, or accepted standards of medical practice.
- The dose and duration of treatment is supported by one of the following compendia: American Hospital Formulary Service (AHFS) Compendia; Thomson Reuters (Healthcare) Micromedex/DrugDex (not Drug Points) Compendium; Elsevier Gold Standards Clinical Pharmacology Compendium; National Comprehensive Cancer Network Drugs and Biologics Compendium.
The requested quantity of the medication is appropriate for the body surface area being treated and for the days supply being requested (document body surface area being treated and dosing instructions).
Requires documentation of BSA and dosing instructions.

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required for Topical Products Meeting Dollar Threshold

Topical products that meet an internal dollar threshold require prior authorization/notification and must meet the policy criteria; authorization will be issued for 12 months. Document body surface area being treated and dosing instructions when requesting authorization.

Authorization duration: 12 months
Trigger: products meeting an internal dollar threshold require prior authorization/notification

Documentation Required

Clinical Support Documentation

Provide evidence that indication and dose/duration are supported by FDA labeling, peer-reviewed literature, accepted standards of medical practice, or listed compendia; include body surface area and dosing instructions to justify quantity.

Evidence of indication (FDA labeling, peer‑reviewed literature, accepted standards, or listed compendia)
Evidence to support dose and duration (FDA labeling, peer‑reviewed literature, accepted standards, or listed compendia)
Document body surface area (BSA) being treated
Provide dosing instructions to justify quantity/days supply

Billing Rule

State and Plan Limitations Apply

State mandates, federal regulatory requirements, member-specific benefit plan coverage, and other policies/utilization management programs may impact coverage.

Definitions & Background

Topical medications include products applied locally to body surfaces such as the skin or mucous membranes and encompass dosage forms including creams, lotions, ointments, foams and gels. UnitedHealthcare uses a dollar threshold to identify topical products that require prior authorization/notification; those products must meet the policy criteria for indication, dose/duration, and quantity appropriateness to be covered, and authorization is issued for 12 months.

Topical medications: Products applied locally to body surfaces such as the skin or mucous membranes, including creams, lotions, ointments, foams and gels.