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L.5.01.572
Vectical (calcitriol) ointment
Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
Psoriasis is an immune-mediated, chronic inflammatory skin disease that ranges in severity from mild and localized to severe and diffuse. Topical corticosteroids are considered the first line therapy for psoriasis but are not intended for prolonged use due to the risk of adverse effects and reduced therapeutic benefit with continued use. Topical vitamin D analogs can be used alone or in combination with topical corticosteroids as an effective alternative for the treatment for psoriasis. Vitamin D analogs are thought to inhibit the proliferation and promote the differentiation of keratinocytes of lesional psoriatic skin.
Vectical (calcitriol) ointment is a vitamin D3 analog indicated for the topical treatment of mild to moderate plaque psoriasis in adults and pediatric patients 2 years and older.
Prior authorization is required.
The use of samples by an individual will not be considered current or stable therapy to satisfy Medical Policy requirements.
Initial Criteria
Vectical (calcitriol) ointment may be considered medically necessary when ALL of the following are met:
The individual is ≥2 years of age;
The individual has a documented diagnosis of plaque psoriasis;
BOTH of the following:
The individual has tried and had an inadequate response (see definition of “Medication Failure” in Policy Guidelines section), an intolerance, or an FDA-labeled contraindication to treatment with TWO topical corticosteroids; AND
The individual has tried and
had an inadequate response
(see definition of “Medication Failure” in Policy Guidelines section), an intolerance, or an FDA-labeled contraindication to treatment with topical calcipotriene; AND
The prescribed dosage is within the program quantity limits based on FDA approved labeled dosage.
Length of Approval: 12 months
Renewal Criteria
Vectical (calcitriol) ointment may be approved for RENEWAL when ALL of the following criteria are met:
The individual was previously approved for therapy with the requested agent through BCBSMS PA process;
The individual has documented clinical improvement (i.e., decrease in BSA affected, decrease in symptoms, etc.); AND
The prescribed dosage is within the program quantity limits based on FDA approved labeled dosage.
Length of Approval: 12 months
State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
appropriate with regard to standards of good medical practice; and
not solely for the convenience of the Member, his or her Provider; and
the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
BCBSMS may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.
Medication Failure is defined as disease progression despite maximally tolerated dose (≥3 months use) as appropriate for disease state being treated. Experience of common side effects of medication will not be considered medication failure for the purpose of this review.
BCBSMS determines individual medication trial and adherence by a review of pharmacy claims data over the preceding twelve months. Additional information may be requested on a case-by-case basis to allow for proper review. If individual is new to BCBSMS and pharmacy records are needed to confirm medication trials and adherence, it is the responsibility of the individual and/or requesting provider to obtain said records and to submit them to BCBSMS upon request. Medical records from the provider that list previously prescribed medications will not be sufficient to show medication trials or adherence.
07/28/2020: New policy added. Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee.
07/13/2021: Policy reviewed and approved by Pharmacy & Therapeutics (P&T) Committee. Policy description updated regarding indications for Vectical (calcitriol) ointment. Policy section updated to revise initial and renewal criteria for Dovonex (calcipotriene) cream and Vectical (calcitriol) ointment. Policy Exceptions updated. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Added information regarding BCBSMS request for medical records and removed investigative definition. Sources updated.
02/01/2023: Policy Exceptions updated to add the following: State Health Plan (State and School Employees): The prescription drug(s) in this medical policy may be covered under a prescription drug benefit plan administered by the State Health Plan’s Pharmacy Benefit Manager. Please perform a formulary drug search at https://www.dfa.ms.gov/cvs-caremark and submit any required Prior Authorization Requests for coverage determination to the Plan’s Pharmacy Benefit Manager. Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary. Services related to delivery and/or administration of a self-administered drug are not covered.
10/01/2024: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy description and policy statements updated to remove indications and medically necessary criteria for Dovonex (calcipotriene) cream. Policy language updated to change "member" to "individual." Sources updated.
09/09/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy description and policy section revised with minor changes for clarity purposes; intent unchanged. Deleted the following criteria: The medication is being prescribed by, or in consultation with, a board certified dermatologist. Sources updated.
Kim, G. “The Rationale Behind Topical Vitamin D Analogs in the Treatment of Psoriasis: Where Does Topical Calcitriol Fit In?” Journal of Clinical and Aesthetic Dermatology. 3.8 (August 2010): 46-53. Web. May 2020.
Vectical prescribing information. Galderma Laboratories, L.P. October 2024. Last accessed July 2025.
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