Continuation of Therapy — Calcipotriene and Calcipotriene/Betamethasone Topical Products
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Defines prior authorization and reauthorization requirements for pharmacy benefit coverage of calcipotriene (vitamin D analogue) topical products and calcipotriene/betamethasone combination products for treatment of plaque psoriasis for Mass General Brigham Health Plan commercial/exchange members.
Updated policy to reflect that calcipotriene foam and Sorilux are moving to nonformulary status and updated language for members who are new to the Plan.
Removed calcipotriene/betamethasone ointment from the policy as the agent moved to nonformulary status.
Coverage Criteria for Calcipotriene and Combination Products
Initial authorization criteria by product
Authorization may be granted when ALL of the following product-specific criteria are met:
ALL of the following
calcipotriene cream/ointment/solution
- Member is ≥ 12 years of age
- Member is diagnosed with plaque psoriasis
- Has had an inadequate response, intolerance, or contraindication to a generic topical corticosteroid
Initial therapy criteria
Initial authorization product-specific criteria:
ALL of the following
calcipotriene + betamethasone dipropionate suspension
- Member is ≥ 12 years of age
- Member is diagnosed with plaque psoriasis
- Has had an inadequate response, intolerance, or contraindication to calcipotriene and betamethasone dipropionate used concurrently as separate agents
Initial Therapy Criteria
Initial therapy criteria
Initial authorization product-specific criteria:
ALL of the following
Enstilar (calcipotriene/betamethasone foam)
- Member is ≥ 12 years of age
- Member is diagnosed with plaque psoriasis
- Has had an inadequate response, intolerance, or contraindication to calcipotriene and betamethasone dipropionate used concurrently as separate agents
- Has had an inadequate response, intolerance, or contraindication to a generic calcipotriene and betamethasone dipropionate combination product
Continuation of Therapy
Continuation of Therapy
Reauthorization requirement:
ALL of the following
- Submission of medical records documenting improvement
- Approvals will be for 12 months
Prior Authorization and Provider Requirements
Prior authorization, new-member documentation, and reauthorization requirements
Prior authorization is required for calcipotriene topical products and calcipotriene/betamethasone products under the pharmacy benefit. For members who are new to the Plan (coverage effective date ≤ 90 days), submit medical records documenting that the member is currently receiving the requested drug (excluding samples or manufacturer patient assistance programs). For initial authorization, ensure product-specific criteria are met (age ≥ 12 years, diagnosis of plaque psoriasis, and the specified prior failure/intolerance/contraindication requirements). For continuation/reauthorization, submit medical records/chart notes documenting improvement of the member’s condition; approvals will be for 12 months.
- Prior authorization program applies (Pharmacy Benefit; Program Type: Prior Authorization).
- For new-to-plan members (coverage effective date ≤ 90 days), include medical records showing current receipt of the requested drug — exclude samples and manufacturer patient assistance program supplies.
- Initial authorization must meet product-specific criteria: member ≥ 12 years, diagnosis of plaque psoriasis, and required prior inadequate response/intolerance/contraindication to specified comparators per product.
- Reauthorization requires submission of medical records/chart notes documenting clinical improvement; approvals are for 12 months.
Definitions
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