Calcipotriene/Betamethasone Dipropionate Foam (Enstilar)
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Policy governing medical necessity and prior authorization criteria for Enstilar topical foam for treatment of plaque psoriasis in covered members; applies to Health Net lines of business including Commercial, HIM, and Medicaid where noted.
No material clinical or coverage changes in this revision.
Coverage Criteria for Enstilar (Calcipotriene/Betamethasone Foam)
Initial Approval Criteria — Plaque Psoriasis
Covered when ALL of the following are met:
Approval duration: 1 month
Continued Therapy (Plaque Psoriasis)
Covered for continuation when one of the following is met:
Approval duration: Up to 1 month of total treatment (a single continuous course up to 4 weeks is recommended)
Other Diagnoses/Indications
For non-covered or off-label uses
Refer to the listed policies
Non‑FDA approved indications that are not specifically addressed in this policy are not authorized unless the provider submits sufficient documentation demonstrating efficacy and safety in accordance with the applicable off‑label use policies (CP.CPA.09 for commercial, HIM.PA.154 for Health Insurance Marketplace, CP.PMN.53 for Medicaid) or other evidence of coverage documents.
For members covered by Medicaid, state Medicaid coverage provisions take precedence when they conflict with this clinical policy; providers should consult the applicable state Medicaid manual for specific coverage requirements and follow those provisions where different from this policy.
Use of this drug for non‑FDA approved indications without sufficient supporting documentation is considered not authorized. Providers must follow the referenced off‑label use policies and submit clinical evidence per those policies to support any request for coverage of off‑label use.
Product Coding and Dosing Information
| 0.005%/0.064% | Can containing 0.005% calcipotriene/0.064% betamethasone dipropionate foam: 60 g, 120 g (2 cans of 60 g) |
Provider Actions, Prior Authorization and Documentation
Prior authorization required for Enstilar when coverage criteria met
Prior authorization is required. Enstilar (calcipotriene/betamethasone foam) is considered medically necessary for plaque psoriasis only when the policy's specified criteria are met (diagnosis of plaque psoriasis, patient age ≥12 years, required prior topical therapy failures, and dosing within the stated limit).
- Approval duration: 1 month for initial therapy; continued therapy approval up to 1 month when continuation criteria are met.
- Dose limit: does not exceed 60 g every 4 days (7 cans per month).
No explicit PA codes or alternate PA requirements stated
No additional or separate prior authorization codes or alternate prior authorization pathways are specified in the policy text.
Document prior topical failures before approval
Prior topical therapy failures must be documented: the member must have failed a medium- to ultra‑high‑potency topical corticosteroid and failed one of calcipotriene, calcitriol, or tazarotene unless contraindicated or adverse effects prevent use.
- Failure of a medium to ultra-high potency topical corticosteroid (see Appendix B for agents and potency guidance) unless contraindicated or intolerant.
- Failure of one of: calcipotriene, calcitriol (Vectical), or tazarotene unless clinically significant adverse effects or contraindications exist.
No other step therapy requirements stated
The policy does not list any other separate step therapy requirements beyond the prior topical failures already specified.
Required submission: clinical documentation must be provided
Provider must submit supporting clinical documentation with the prior authorization request, such as office chart notes, laboratory results, and other clinical information demonstrating the member meets all approval criteria.
- Include documentation of diagnosis (plaque psoriasis), patient age, prior topical therapy trials and outcomes, and current dosing.
- Include notes showing response to therapy for continuation requests.
Coverage decisions subject to plan terms and law
This clinical policy is a guide to medical necessity and used to assist coverage decisions; final coverage and benefit payment remain subject to the member's plan terms, exclusions, limitations, and applicable law.
- Coverage decisions are subject to the member's evidence of coverage, contract, and applicable state/federal requirements.
Denial risk: insufficient or missing documentation
Failure to submit the required supporting documentation (office chart notes, lab results, or other clinical information) may result in denial of the prior authorization request.
Medicaid precedence: follow state Medicaid provisions when they conflict
For Medicaid members, state Medicaid coverage provisions take precedence when they conflict with this clinical policy; providers must follow applicable state Medicaid manual provisions to avoid coverage differences or denials.
Background on Product and Indication
Enstilar is a fixed‑combination topical foam that contains a vitamin D analog and a corticosteroid — calcipotriene 0.005% and betamethasone dipropionate 0.064% — indicated for the topical treatment of plaque psoriasis (PsO) in patients aged 12 years and older. Typical administration is topical application to affected areas once daily, with treatment courses generally limited to a single continuous course of up to 4 weeks; providers should avoid use on the face, groin, axillae, areas of skin atrophy, and under occlusive dressings unless directed by a clinician.
Definitions and Abbreviations
Revision History
4Q 2024 annual review conducted; no significant clinical changes and references reviewed/updated.
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