Pharmacy Prior Authorization Criteria

Sernivo (betamethasone dipropionate)

Indications for Prior Authorization

Sernivo (betamethasone dipropionate)

• For diagnosis of Plaque Psoriasis
  Indicated for the treatment of mild to moderate plaque psoriasis in patients 18 years of age or older.

Criteria

Sernivo

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure within the past 180 days, contraindication, or intolerance to three of the following:
• Clocortolone 0.1% cream
• Fluocinolone acetonide 0.025% ointment
• Flurandrenolide 0.05% ointment
• Fluticasone propionate 0.05% cream
• Hydrocortisone valerate 0.2% ointment
• Mometasone furoate 0.1% cream/lotion/solution
• Triamcinolone 0.1% cream/ointment
• Triamcinolone 0.05% ointment
• Triamcinolone aerosol spray
• Brand/generic Taclonex (calcipotriene-betamethasonne dipropionate) suspension
• Enstilar foam

P & T Revisions

2025-02-16, 2024-01-31, 2023-01-29, 2022-06-21, 2022-05-04, 2022-02-04

References

1. Sernivo Prescribing Information. Encore Dermatology, Inc. Scottsdale, AZ. March 2020.

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Revision History

• 2025-02-16: Annual review - no criteria changes
• 2024-01-31: Annual review - no criteria changes
• 2023-01-29: Annual review - no criteria changes
• 2022-06-21: Update to add approval length to GL. No criteria changes.
• 2022-05-04: Adding a lookback period of 180 days. Updated references.
• 2022-02-04: New ST for Sernivo

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