CurrentUnitedHealthcarePolicy N/A

Topical antifungal prior authorization (nystatin/clotrimazole products)

Formulary prior authorization form governing coverage of topical antifungal/antimycotic creams and ointments for beneficiaries; affects prescribers submitting PA requests for these topical products.

Policy Summary

PayerUnitedHealthcare

PolicyTopical antifungal prior authorization (nystatin/clotrimazole products)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form with beneficiary and prescriber information, patient age verification, prescriber signature, and documentation of two prior topical prescription failures within 60 days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥4 wmin age

50 gmquantity limit

2required failures

60 dlookback

Coverage Criteria

Initial Authorization Criteria

Policy Summary

PayerUnitedHealthcare

PolicyTopical antifungal prior authorization (nystatin/clotrimazole products)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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Form completed: PA form completed with beneficiary and prescriber information, drug name/strength/quantity, prescriber signature and date.

See chunks 0-2 for required fields and chunk 3 for signature requirement

Age requirement: Patient is at least four weeks of age.>=4 weeks

Chunk 3

Step therapy failure: Patient has tried and failed on at least 2 different prescription products from the list (nystatin cream, nystatin ointment, nystatin/triamcinolone cream, nystatin/triamcinolone ointment, or clotrimazole cream) within the past 60 days.2 products within 60 days

Chunk 3

Quantity limit: Requested quantity does not exceed 50 grams per 60 days.<=50 gm per 60 days

Chunk 3

Coverage for topical antifungal/antimycotic creams and ointments is granted when the prior authorization form is completed and all clinical criteria are met. The form must include beneficiary and prescriber information, the drug name, strength, quantity per 30 days, length of therapy selection, and the prescriber’s signature and date. The patient must be at least 4 weeks of age, and the record must document trial and failure of at least 2 different prescription topical products from the listed agents (nystatin cream, nystatin ointment, nystatin/triamcinolone cream, nystatin/triamcinolone ointment, or clotrimazole cream) within the prior 60 days. Requested quantities must not exceed the 50 gm per 60 days limit.

Failure to provide required documentation — including verification that the recipient is at least 4 weeks old or documentation of trial and failure of at least 2 different prescription topical products within the prior 60 days — may result in denial of the authorization. Requests that exceed the 50 gm per 60 days quantity limit are also subject to restriction or denial. Ensure the prescriber’s signature and date are present on the form to avoid administrative denial.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization requests must be submitted using the UnitedHealthcare prior authorization form and include complete beneficiary, prescriber, drug, and clinical information. Incomplete submissions may delay review.

Use the official UnitedHealthcare prior authorization form
Include beneficiary, prescriber, drug, and full clinical details

Step Therapy

Step Therapy / Required Trials

Prior to approval, the patient must have tried and failed on at least two different prescription products from the specified list within the past 60 days. Document the specific products and dates of trial/failure on the form.

Required trials: at least 2 different prescription products within the past 60 days
Examples: nystatin cream, nystatin ointment, nystatin/triamcinolone cream, nystatin/triamcinolone ointment, clotrimazole cream
List products and dates of failure on the PA form

Documentation Required

Required Form Fields and Clinical Documentation

Complete all required beneficiary, prescriber, drug, and clinical fields on the prior authorization form. Include supporting clinical documentation as indicated (e.g., prior treatment history, age confirmation, and prescriber signature).

Beneficiary: last name, first name, beneficiary ID, date of birth, gender
Prescriber: provider name, NPI, requester contact name and phone, prescriber signature and date (signature mandatory)
Drug: drug name, strength, quantity per 30 days, length of therapy (select duration)
Clinical: age confirmation, documentation of prior trials and failures (products and dates), clinical rationale for therapy

Denial Risk

Documentation Triggers for Denial

Requests missing required information—such as patient age, documentation of required prior trials, or prescriber signature—are at high risk for denial. Ensure all fields and supporting documentation are provided to avoid denial.

Missing age confirmation may trigger denial
Absence of documented prior trials/failures may trigger denial
Missing prescriber signature will result in denial

Billing Rule

Quantity Limit

A quantity limit applies: requests exceeding 50 grams per 60 days may be restricted or denied. Indicate requested quantity and length of therapy clearly on the form.

Quantity limit: 50 gm per 60 days
Requests >50 gm per 60 days may be denied or require additional justification

Product tried (list as on form)	Date of trial / failure
nystatin cream
nystatin ointment
nystatin/triamcinolone cream
nystatin/triamcinolone ointment
clotrimazole cream

Background & Definitions

Topical antifungal creams and ointments such as nystatin and clotrimazole are used for superficial fungal infections. This prior authorization form documents age eligibility and prior trials of prescription topical alternatives before coverage is authorized, and it notes a quantity limit of 50 grams per 60 days. The form also requires the prescriber’s signature and dates for attestation.

Quantity limit definition

Defined limit50 grams per 60 days applies to covered topical products

ApplicationLimit referenced for all covered topical prescription products listed on form (e.g., nystatin, clotrimazole)

ConsequenceRequests exceeding 50 gm/60 days are subject to restriction or denial

OpenPayer

Topical antifungal prior authorization (nystatin/clotrimazole products)

Coverage Criteria

Coding / Definitions

Provider Actions & Requirements

Initial Therapy Requirements

Step Therapy / Trial Documentation

Quantity Limits

Background & Definitions