Subject: Antifungal Topical Combinations Limit, Post PA 2912-HJ P04-2026

Drug

Antifungal Topical Combinations

clotrimazole and betamethasone dipropionate (brand unavailable)  (clotrimazole and betamethasone dipropionate)

nystatin and triamcinolone acetonide (brand unavailable)  (nystatin and triamcinolone acetonide)

Policy:

Indications

FDA-approved Indications

Clotrimazole and Betamethasone Dipropionate Lotion

Clotrimazole and betamethasone dipropionate lotion is indicated in patients 17 years and older for the topical treatment of symptomatic inflammatory tinea pedis, tinea cruris, and tinea corporis due to Epidermophyton floccosum, Trichophyton mentagrophytes, and Trichophyton rubrum. Effective treatment without the risks associated with topical corticosteroid use may be obtained using a topical antifungal agent that does not contain a corticosteroid, especially for noninflammatory tinea infections. The efficacy of clotrimazole and betamethasone dipropionate lotion for the treatment of infections caused by zoophilic dermatophytes (e.g., Microsporum canis) has not been established.

Clotrimazole and Betamethasone Dipropionate Cream

Clotrimazole and betamethasone dipropionate cream is a combination of an azole antifungal and corticosteroid and is indicated for the topical treatment of symptomatic inflammatory tinea pedis, tinea cruris, and tinea corporis due to Epidermophyton floccosum, Trichophyton mentagrophytes, and Trichophyton rubrum in patients 17 years and older.

Nystatin and Triamcinolone Acetonide Cream and Ointment

Nystatin and triamcinolone acetonide cream and ointment are indicated for the treatment of cutaneous candidiasis; it has been demonstrated that the nystatin-steroid combination provides greater benefit than the nystatin component alone during the first few days of treatment.

Initial Quantity Limit

Initial Limit Quantity

If the patient is requesting more than the initial quantity limit, the claim will reject with a message indicating that a prior authorization is required. The prior authorization criteria would then be applied to requests submitted for evaluation to the PA unit.

Limits should accumulate across same chemical entity up to highest quantity listed depending on the order the claims are processed. Accumulation does not apply if limit is coded for daily dose.

The duration of 25 days is used for a 30-day fill period to allow time for refill processing. These drugs are for short-term acute use; therefore, the intent is for prescriptions of the requested drug to be filled one month at a time; there should be no 3 month supplies filled.

PLEASE NOTE: Since manufacturer package sizes may vary, it is the discretion of the dispensing pharmacy to fill quantities per package size up to these quantity limits. In such cases the filling limit and day supply may be less than what is indicated.

Drug	1 Month Limit	3 Month Limit
clotrimazole and betamethasone dipropionate lotion	60 mL / 25 days	Does Not Apply
clotrimazole and betamethasone dipropionate cream	60 gm / 25 days	Does Not Apply
nystatin and triamcinolone acetonide cream and ointment	60 gm / 25 days	Does Not Apply

Coverage Criteria

Cutaneous Candidiasis

Authorization may be granted for the treatment of cutaneous candidiasis when ALL of the following criteria are met:

·        The requested drug is NOT being used in a footbath.

·        The request is for nystatin/triamcinolone.

Tinea Corporis, Tinea Cruris, Tinea Pedis

Authorization may be granted for the treatment of tinea corporis, tinea cruris or tinea pedis when ALL of the following criteria are met:

·        The requested drug is NOT being used in a footbath.

·        The request is for clotrimazole/betamethasone.

Quantity Limits Apply

Post Limit Quantity

The duration of 25 days is used for a 30-day fill period to allow time for refill processing. These drugs are for short-term acute use; therefore, the intent is for prescriptions of the requested drug to be filled one month at a time; there should be no 3 month supplies filled.

PLEASE NOTE: Since manufacturer package sizes may vary, it is the discretion of the dispensing pharmacy to fill quantities per package size up to these quantity limits. In such cases the filling limit and day supply may be less than what is indicated.

Drug	1 Month Limit	3 Month Limit
clotrimazole and betamethasone dipropionate lotion	90 mL / 25 days	Does Not Apply
clotrimazole and betamethasone dipropionate cream	90 gm / 25 days	Does Not Apply
nystatin and triamcinolone acetonide cream and ointment	120 gm / 25 days	Does Not Apply

Duration of Approval (DOA)

·        2912-HJ: DOA: 3 months

Place of Service:

Outpatient

The above policy is based on the following references:

1.      Clotrimazole/Betamethasone diproprionate lotion [package insert]. Hawthorne, NY: Taro Pharmaceuticals U.S.A., Inc.; May 2016.

2.     Clotrimazole/Betamethasone diproprionate cream [package insert]. Hawthorne, NY: Taro Pharmaceuticals U.S.A., Inc.; October 2019.

3.     Nystatin/Triamcinolone [package insert]. Hawthorne, NY: Taro Pharmaceuticals Inc.; September 2004.

4.     Lexicomp Online, Lexi-Drugs Online. Waltham, MA: UpToDate, Inc.; 2026. https://online.lexi.com. Accessed February 2, 2026.

5.     Micromedex (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: 02/02/2026).

6.     Vyas JM. National Library of Medicine. Candida Infection of the skin. MedlinePlus. October 9, 2024. Available at: https://medlineplus.gov/ency/article/000880.htm. Accessed February 5, 2026.

7.     Eichenfield L, Tom W, Berger T, et al. Guidelines of Care for the Management of Atopic Dermatitis Section 2. Management and Treatment of Atopic Dermatitis with Topical Therapies. J Am Acad Dermatol. 2014; 71:116-32.

8.     U.S. Department of Health & Human Services. Burn Triage and Treatment – Thermal Injuries. Chemical Hazards Emergency Medical Management. February 2, 2026. Available at: https://chemm.hhs.gov/burns.htm. Accessed February 3, 2026.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

August 20, 2026