CurrentNeighborhood Health Plan of Rhode IslandPolicy 1381-E UDR 07-2023

Vitamin D Analogs Topical ST With Limit Post PA Policy 1381 E Udr 07 2023 1

Defines initial step therapy with quantity limits and post-step-therapy prior authorization criteria for topical Vitamin D analog products (multiple brands/formulations) for treatment of psoriasis under CVS Caremark criteria as used by Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVitamin D Analogs Topical ST With Limit Post PA Policy 1381 E Udr 07 2023 1

Policy CodePolicy 1381-E UDR 07-2023

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf initial step therapy criteria or quantity limits are not met, submit a prior authorization request for evaluation to the PA unit.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — policy remains the same (has_material_change=false).

9Listed product formulations

3 monthsInitial therapy DOA

12 monthsContinuation DOA

Coverage Summary

This policy covers topical Vitamin D analogs (calcipotriene and calcitriol formulations, including combination products with betamethasone such as Enstilar, Taclonex, and Wynzora) with step therapy and product-specific quantity limits; products listed in the policy will be paid without prior authorization only when the initial step therapy criteria and the initial quantity limits are met, otherwise a prior authorization is required. (Scope: topical Vitamin D analogs for psoriasis; Coverage stance: covered_with_criteria.)

Initial Step Therapy with Quantity Limit

Covered without PA when initial step therapy criteria and initial quantity limits are met; otherwise claim rejects and PA required.

ALL of the following

Patient has filled a prescription for at least a 30-day supply of a topical steroid within the past 180 days under a prescription benefit administered by CVS Caremark
Requested drug is prescribed for the topical treatment of chronic, moderately severe psoriasis of the scalp or plaque psoriasis (per product indication)
Quantity requested is within the product-specific initial limit (1 month or 3 month limits as listed)
See product-specific initial limits in policy (1-month and 3-month limits).

Post-Step Therapy Prior Authorization Criteria

Post Step Therapy Prior Authorization - Coverage Criteria

The requested drug will be covered with prior authorization when the following criteria are met:

ALL of the following

EITHER
- The request is NOT for continuation of therapy AND the patient has experienced an inadequate treatment response, intolerance, or has a contraindication to a topical steroid
  Document inadequate response/intolerance/contraindication for new therapy PA.
- The request is for continuation of therapy AND the patient has achieved or maintained a positive clinical response to the requested drug (e.g., clear, or almost clear outcome, patient satisfaction, etc.)
  Document positive clinical response for continuation PA.
Quantity justification (when additional quantities requested)
- If additional quantities requested for Vectical (calcitriol ointment): prescribed to treat a body surface area that requires more than 100 grams per month> 100 grams per month
- If additional quantities requested for Calcipotriene Topical Scalp Solution, Calcitrene Ointment, Dovonex Cream, Enstilar Foam, Sorilux Foam, Taclonex Ointment, Taclonex Suspension, or Wynzora Cream: prescribed to treat a body surface area that requires more than 60 units per month> 60 units per month

ref

title

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Duration of Approval (DOA)

ALL of the following

Initial therapy DOA: 3 months3 months
Continuation of therapy DOA: 12 months12 months

Limitations & Exclusions

Coverage, initial quantity limits, and prior authorization criteria apply per product and per the indications and limitations summarized from each product’s package insert; the policy’s listed products and formulations define the scope — products not listed in the policy code groups are outside the scope of this document. Product-specific limits and indications (for example, scalp solution versus ointment/cream/foam and age-based indications) are provided in the package-insert summaries and the policy’s initial limit tables.

Applicable Drug Products (NDC / Product List)

Drug products listed (by brand/generic)NDC|mixedCovered

Calcipotriene Topical Scalp Solution 0.005%	Brand/generic: calcipotriene topical scalp solution; indicated for chronic, moderately severe psoriasis of the scalp
Calcitrene (calcipotriene) Ointment 0.005%	Ointment indicated for plaque psoriasis in adults
Dovonex (calcipotriene) Cream 0.005%	Cream indicated for plaque psoriasis
Enstilar (calcipotriene/betamethasone dipropionate) Foam 0.005%/0.064%	Foam indicated for plaque psoriasis in patients 12 years and older
Sorilux (calcipotriene) Foam 0.005%	Foam indicated for plaque psoriasis of scalp and body in patients 4 years and older
Taclonex (calcipotriene/betamethasone dipropionate) Ointment 0.005%/0.064%	Ointment indicated for plaque psoriasis in patients 12 years and older
Taclonex (calcipotriene/betamethasone dipropionate) Topical Suspension 0.005%/0.064%	Suspension indicated for plaque psoriasis of scalp and body in patients 12 years and older
Vectical (calcitriol) Ointment 3 mcg/g	Ointment indicated for mild to moderate plaque psoriasis in adults and pediatric patients 2 years and older
Wynzora (calcipotriene/betamethasone dipropionate) Cream 0.005%/0.064%	Cream indicated for plaque psoriasis in patients 18 years and older

Provider Actions & Billing Rules

Prior Authorization

PA required when step criteria not met or quantity exceeds initial limit

If the patient does not meet the initial step therapy criteria or requests quantities exceeding the initial limit, the claim will reject and a prior authorization request must be submitted for evaluation to PA unit.

Claim will reject and a PA must be submitted to the PA unit.

Documentation Required

Documentation required for PA

For new therapy PA: document inadequate treatment response, intolerance, or contraindication to a topical steroid; for continuation PA: document achieved or maintained positive clinical response (e.g., clear or almost clear, patient satisfaction).

New therapy PA: evidence of inadequate treatment response, intolerance, or a contraindication to a topical steroid.
Continuation PA: documentation of achieved or maintained positive clinical response (e.g., clear or almost clear, patient satisfaction).

Billing Rule

Initial quantity limits apply per drug/strength

Claims will pay only up to the product-specific initial limits (1 month or 3 month) listed; initial limits use 25 days for 30-day fills and 75 days for 90-day fills to allow refill processing.

The 25-day convention is used for a 30-day fill and 75 days for a 90-day fill to allow time for refill processing.
Claims will pay only up to the product-specific initial limits (1-month or 3-month amounts) listed for each drug/strength.

Quantity Thresholds & Justification

Additional quantity thresholds

Vectical additional quantity threshold> 100 grams per month

Other products additional quantity threshold> 60 units per month

When requested quantities exceed the product-specific initial limits, a quantity justification is required as part of the prior authorization: for Vectical (calcitriol) additional quantities must be justified by a body-surface-area requirement of more than 100 grams per month, and for Calcipotriene Topical Scalp Solution, Calcitrene Ointment, Dovonex Cream, Enstilar Foam, Sorilux Foam, Taclonex formulations, or Wynzora Cream additional quantities must be justified by a body-surface-area requirement of more than 60 units per month.

Clinical Evidence & References

References for product indications and limitations of use include the individual package inserts for the listed products (Calcipotriene Topical Scalp Solution; Calcitrene Ointment; Dovonex Cream; Enstilar Foam; Sorilux Foam; Taclonex Ointment and Suspension; Vectical Ointment; Wynzora Cream) and guideline sources such as the Joint AAD‑NPF Guidelines of Care for the management and treatment of psoriasis with topical therapy (J Am Acad Dermatol 2020), as well as Lexicomp and Micromedex cited in the policy reference list.

Background

This policy defines initial step therapy and product-specific quantity limits for topical Vitamin D analogs (calcipotriene and calcitriol products, alone or combined with betamethasone) used to treat psoriasis; the policy summarizes product indications and limitations of use from each product’s package insert and applies CVS Caremark criteria for step therapy, initial limits (1‑month and 3‑month limits expressed as 25‑day and 75‑day durations for processing), and post‑step‑therapy prior authorization requirements.

Scope summaryDefines initial step therapy with quantity limits and post-step-therapy prior authorization criteria for topical Vitamin D analog products for treatment of psoriasis under CVS Caremark criteria as used by Neighborhood Health Plan of Rhode Island.

policy_number1381-E UDR 07-2023

subjectTopical Vitamin D Analogs (calcipotriene/calcitriol) step therapy and quantity limits

statusCURRENT

last_review2023-07-??

effective

next_review

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVitamin D Analogs Topical ST With Limit Post PA Policy 1381 E Udr 07 2023 1

Policy CodePolicy 1381-E UDR 07-2023

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf initial step therapy criteria or quantity limits are not met, submit a prior authorization request for evaluation to the PA unit.

SourceLink

On This Page

OpenPayer

Vitamin D Analogs Topical ST With Limit Post PA Policy 1381 E Udr 07 2023 1

Coverage Summary

Post-Step Therapy Prior Authorization Criteria

Limitations & Exclusions

Applicable Drug Products (NDC / Product List)

Provider Actions & Billing Rules

Quantity Thresholds & Justification

Clinical Evidence & References

Background

Revision History