CurrentNeighborhood Health Plan of Rhode IslandPolicy 1381-E

Topical Vitamin D Analogs (calcipotriene/calcitriol) — Step Therapy and Post‑Step Prior Authorization with Quantity Limits

Step therapy and prior authorization rules with product-specific quantity limits for topical vitamin D analog products used to treat plaque psoriasis; applies to prescriptions processed under CVS Caremark for the payer.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTopical Vitamin D Analogs (calcipotriene/calcitriol) — Step Therapy and Post‑Step Prior Authorization with Quantity Limits

Policy CodePolicy 1381-E

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization when step therapy criteria are not met or when requested quantities exceed initial limits; for continuation, document a positive clinical response.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 monthsInitial DOA

12 monthsContinuation DOA

60/180 or 120/360Common qty limits

25 / 75Processing days

Coverage Criteria

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Coverage criteria (initial and continuation)

Covered with prior authorization when the following criteria are met:

Primary indication: The requested drug is being prescribed for the treatment of psoriasis

Non-continuation requests: For requests that are NOT continuation of therapy: the patient has experienced an inadequate treatment response, intolerance, or has a contraindication to a topical steroid

If additional quantities requested for Vectical exceed 100 g/month or for other listed products exceed 60 units/month then the appropriate higher quantity limit criteria must be met (see quantity limits).

Continuation requests: For requests that ARE continuation of therapy: the patient has achieved or maintained a positive clinical response to the requested drug (e.g., clear or almost clear, patient satisfaction).

Continuation of Therapy

Covered when ALL of the following are met

Continuation criteria: Request is for continuation of therapy AND patient has achieved or maintained a positive clinical response (e.g., clear, or almost clear outcome, patient satisfaction)

Continuation approvals align with listed quantity equivalents and DOA

Duration of Approval

Duration of Approval: Initial therapy: 3 months; Continuation of therapy: 12 months

DOA as specified in policy 1381-E

Vectical (calcitriol) ointment has a labeled limitation regarding systemic calcium handling: the safety and effectiveness of Vectical Ointment in patients with known or suspected disorders of calcium metabolism have not been evaluated. Providers should consider this limitation when prescribing Vectical and document clinical rationale if used in patients with possible calcium‑metabolism abnormalities.

The policy does not list specific clinical exclusion diagnoses beyond product labeling limitations. Coverage criteria require that the drug is prescribed for psoriasis and that continuation requests demonstrate clinical benefit, but no other explicit exclusion conditions are specified in the provided policy excerpt.

Continuation authorizations require evidence that the patient has achieved or maintained a positive clinical response (for example, clear or almost clear outcome or patient satisfaction). Requests for continuation that fail to document ongoing clinical benefit are implied to be not medically necessary and may be denied.

Initial Therapy Criteria

Initial therapy

Initial step therapy with quantity limits

Step requirement: Patient has filled at least a 30-day supply of a topical steroid within the past 180 days under the CVS Caremark benefit30 days within 180 days

If not met, claim will reject and prior authorization is required; if met, initial quantity limits apply.

Initial quantity limits: Product- and strength-specific initial (1-month/25-day) and 3-month/75-day quantity limits apply (examples in policy).See quantity limits in policy

Durations of 25 and 75 days map to 30- and 90-day fills for processing.

Initial therapy — time limitation

Initial authorizations are time-limited.

Initial therapy DOA: Initial therapy duration of approval = 3 months

See policy for quantity equivalents

Continuation Therapy Criteria

Continuation therapy

Continuation of therapy coverage requirement

Continuation: Request is for continuation and patient has achieved or maintained a positive clinical response to the requested drug

Quantity limits for continuation are higher (see quantity_limits).

Continuation therapy — documentation and duration

Continuation requests must show continued benefit; duration limits apply.

Continuation: Request is for continuation of therapy AND patient has achieved or maintained a positive clinical response

Continuation DOA = 12 months

Step	Requirement	Consequence if not met
1
Patient has filled at least a 30-day supply of a topical steroid within the past 180 days under a prescription benefit administered by CVS Caremark
If not met, the claim will reject with a message indicating that prior authorization (PA) is required and PA criteria will be applied

Provider Actions & Prior Authorization

Prior Authorization

Post-step Prior Authorization Required

If the patient does not meet the initial step therapy criteria (has not filled at least a 30-day topical steroid within the past 180 days) or the requested quantity exceeds the stated initial limit, the claim will reject with a message indicating a prior authorization (PA) is required. The PA unit will then evaluate the request against the prior authorization criteria.

Initial step requirement: patient must have filled a ≥30-day topical steroid within past 180 days under the prescription benefit administered by CVS Caremark.
Claims will reject and require PA when step criteria are not met or when requested quantity exceeds the initial limit.

Denial Risk

Documentation Required for Continuation — Denial Risk if Unmet

Continuation requests require documentation that the patient has achieved or maintained a positive clinical response to the requested topical vitamin D analog (for example, clear or almost clear outcome, patient satisfaction, or comparable clinical benefit). Requests lacking adequate documentation of ongoing benefit may be denied.

Continuation therapy must demonstrate positive clinical response (e.g., clear or almost clear, patient satisfaction).
Denial risk if documentation of continued clinical benefit is not provided.

Documentation Required

Clinical Response Documentation

Providers should document objective or subjective evidence of treatment benefit when requesting continuation of therapy. Acceptable documentation includes clinical notes reporting clear or almost clear outcomes, documented patient-reported improvement or satisfaction, and other clinical assessments that demonstrate ongoing efficacy.

Examples of acceptable documentation: clinical assessment showing clear/almost clear skin, chart notes indicating patient satisfaction or symptom improvement.
Include quantity justification when requesting amounts above the listed monthly limits (e.g., body surface area requiring >60 units/month or >100 g/month for specific products).

Step Therapy

Step Therapy Specifics Not Present in This Excerpt

This excerpt does not include the full step-therapy algorithm details or additional step specifics beyond the initial 30-day topical steroid requirement and quantity limits — providers should refer to the full policy for complete step-therapy instructions.

No further step therapy specifics are present in this section; see full policy for step sequencing and any exceptions.

Product Coding & Equivalences

Product quantity equivalence listingsNDC | product descriptions

Taclonex 0.005%/0.064% Suspension 120 g	Taclonex (calcipotriene/betamethasone diproprionate) Suspension 0.005%/0.064%, 1 = 120 grams / 25 days
Taclonex 0.005%/0.064% Suspension 360 g	Taclonex (calcipotriene/betamethasone diproprionate) Suspension 0.005%/0.064%, 2 = 360 grams / 75 days
Vectical 3 mcg/g Ointment 200 g	Vectical (calcitriol) Ointment 3 mcg/g, 1 = 200 grams / 25 days
Vectical 3 mcg/g Ointment 600 g	Vectical (calcitriol) Ointment 3 mcg/g, 2 = 600 grams / 75 days
Wynzora 0.005%/0.064% Cream 120 g	Wynzora (calcipotriene/betamethasone diproprionate) Cream 0.005%/0.064%, 1 = 120 grams / 25 days
Wynzora 0.005%/0.064% Cream 360 g	Wynzora (calcipotriene/betamethasone diproprionate) Cream 0.005%/0.064%, 2 = 360 grams / 75 days

Quantity Limits by Product

Calcipotriene topical scalp solution 0.005% — quantity limits

ProductCalcipotriene topical scalp solution 0.005%

Initial quantity limit (1-month / 25 days)60 mL

Initial quantity limit (3-month / 75 days)180 mL

PA noteHigher PA limits available when treating BSA requiring >60 units/month (see policy) — requests for additional quantities require PA

Multiple products — initial and PA quantity limits

ProductsCalcitrene ointment, Dovonex cream, Enstilar foam, Sorilux foam, Taclonex ointment/suspension, Wynzora cream

Initial quantity limit (1-month / 25 days)60 grams

Initial quantity limit (3-month / 75 days)180 grams

PA higher limitsUp to 120 grams / 360 grams for select products when treating larger BSA; PA required for higher quantities

Vectical (calcitriol) ointment 3 mcg/g — quantity limits

ProductVectical (calcitriol) ointment 3 mcg/g

Initial quantity limit (1-month / 25 days)100 grams

Initial quantity limit (3-month / 75 days)300 grams

PA limitsPost-authorization limits up to 200 grams / 600 grams

Taclonex Suspension — quantity equivalence

ProductTaclonex Suspension (calcipotriene/betamethasone diproprionate) 0.005%/0.064%

Quantity equivalence — 1120 grams / 25 days

Quantity equivalence — 2360 grams / 75 days

Vectical Ointment — quantity equivalence (alternate)

ProductVectical Ointment (calcitriol) — alternative listing

Quantity equivalence — 1200 grams / 25 days

Quantity equivalence — 2600 grams / 75 days

Wynzora Cream — quantity equivalence

ProductWynzora (calcipotriene/betamethasone diproprionate) Cream 0.005%/0.064%

Quantity equivalence — 1120 grams / 25 days

Quantity equivalence — 2360 grams / 75 days

Products, Indications & Definitions

Products and indications — topical vitamin D analogs

Calcipotriene formulations indicationCalcipotriene topical scalp solution, ointment, cream, and foam are indicated for topical treatment of plaque psoriasis (scalp and/or body) per product labeling.

Combination productsCalcipotriene/betamethasone combination products (Enstilar, Taclonex, Wynzora) are indicated for plaque psoriasis; age indications vary by product.

Vectical indication and limitationVectical (calcitriol) ointment indicated for mild to moderate plaque psoriasis in patients ≥2 years; safety not evaluated in patients with known or suspected disorders of calcium metabolism.

Continuation of therapy — definition and requirements

DefinitionContinuation of therapy is a request where the patient has already been treated with the requested topical vitamin D analog and the provider requests ongoing coverage.

Documentation requiredFor continuation requests, the provider must document that the patient has achieved or maintained a positive clinical response (e.g., clear or almost clear, patient satisfaction).

Approval durationContinuation approvals align with quantity equivalents and duration of approval = 12 months per policy 1381-E.

Background

Topical vitamin D analogs—calcipotriene formulations (scalp solution, ointment, cream, foam) and calcitriol ointment—are indicated for the topical treatment of plaque psoriasis, including scalp formulations where labeled. Several combination products pair a vitamin D analog with betamethasone for enhanced efficacy in indicated age groups. Product labeling includes age and formulation‑specific indications and important safety notes; for example, Vectical (calcitriol) ointment carries a limitation that its safety and effectiveness have not been evaluated in patients with known or suspected disorders of calcium metabolism.