Pharmacy Prior Authorization Criteria

Sernivo (betamethasone dipropionate)

Indications for Prior Authorization

Sernivo (betamethasone dipropionate)

• For diagnosis of Mild to moderate 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

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

• 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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