ModifiedCentenePolicy CP.PMN.182

Betamethasone Dipropionate Spray (Sernivo) — Coverage Criteria

Covers medical necessity, prior authorization, and continuation criteria for Sernivo (betamethasone dipropionate 0.05% spray) for treatment of plaque psoriasis in adults across Centene lines of business.

Policy Summary

PayerCentene

PolicyBetamethasone Dipropionate Spray (Sernivo) — Coverage Criteria

Policy CodePolicy CP.PMN.182

Change TypeAdded step therapy bypass for Illinois HIM per IL HB 5395

Effective DateDec 1, 2018

Next Review Date

Key ActionSubmit prior authorization with office chart notes or other clinical documentation showing diagnosis, age ≥18, prior topical therapy failures or contraindications, and dosing within limits.

SourceLink

POLICY UPDATE CHANGES

Added step therapy bypass for Illinois HIM per IL HB 5395.

Updated product availability strength per prescriber information.

4Q 2025 annual review: no significant changes; added step therapy bypass for IL HIM per IL HB 5395; references reviewed and updated.

4Q 2024 annual review: no significant changes; for product availability section, updated strength per prescriber information; references reviewed and updated.

0.05%drug concentration

≥18minimum patient age

≤120 mL/4wkmax dose

1 moinitial approval length

4Q 2025most recent review

Coverage Criteria

Initial Therapy — Plaque Psoriasis

Covered when ALL of the following are met

Plaque Psoriasis initial approval: 1. Diagnosis of plaque psoriasis (PsO); 2. Age ≥ 18 years; 3. Failure of a medium to ultra-high potency topical corticosteroid (see Appendix B), unless contraindicated or clinically significant adverse effects are experienced (Note: For Illinois HIM requests, step therapy requirements do not apply as of 1/1/2026 per IL HB 5395); 4. Failure of one of the following unless contraindicated or clinically significant adverse effects are experienced: calcipotriene, calcitriol, or tazarotene (Note: For Illinois HIM requests, step therapy requirements do not apply as of 1/1/2026 per IL HB 5395); 5. Requested dose does not exceed 120 mL every 4 weeks.

Approval duration: 1 month

Continued Therapy — Plaque Psoriasis

Covered when ALL of the following are met

Plaque Psoriasis continuation: 1. Member meets one of the following: (a) currently receiving medication via the Centene benefit or previously met initial approval criteria, or (b) currently receiving medication and continuity of care regulations apply for the member's state/product; 2. Member is responding positively to therapy; 3. If request is for a dose increase, the new dose does not exceed 120 mL every 4 weeks.

Policy Summary

PayerCentene

PolicyBetamethasone Dipropionate Spray (Sernivo) — Coverage Criteria

Policy CodePolicy CP.PMN.182

Change TypeAdded step therapy bypass for Illinois HIM per IL HB 5395

Effective DateDec 1, 2018

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for treatment of plaque psoriasis with this medication. Approval is contingent on meeting all plaque psoriasis criteria, including age ≥ 18 years, documentation of diagnosis of psoriasis, prior failure of required topical therapies (unless contraindicated), and dose limits. For Illinois Health Insurance Marketplace (HIM) requests on or after 1/1/2026, the step therapy requirements described below do not apply per IL HB 5395.

Policy Number: CP.PMN.182
Effective Date: 2018-12-01
Approval duration: 1 month

Documentation Required

Required Clinical Documentation

Provider must submit clinical documentation supporting that the member meets all approval criteria. Requests that lack necessary documentation may be denied.

Acceptable documentation: office chart notes, relevant lab results, prior treatment records, and other clinical information demonstrating failure or contraindication to required therapies

Denial Risk

Documentation and Criteria Failure May Lead to Denial

Requests that do not demonstrate that the member meets all approval criteria (for example: diagnosis, age requirement, and prior treatment failures or contraindications) may be denied.

Failure to provide documentation of prior use or intolerance of a medium to ultra-high potency topical corticosteroid and one of calcipotriene, calcitriol, or tazarotene (unless contraindicated) is grounds for denial
Non-FDA approved indications are not authorized unless supported by applicable off-label policies and evidence of coverage documents

Billing Rule

Exceeded Dose Limit

Dose limits are enforced. Requests exceeding the established quantity may be denied.

Dose limit: does not exceed 120 mL every 4 weeks

Step Therapy

Step Therapy Requirements and IL HIM Bypass

Step therapy requires failure of specified topical agents prior to approval unless clinically contraindicated or significant adverse effects occurred. Illinois HIM members are exempt from step therapy requirements per IL HB 5395 effective 1/1/2026.

Required step therapy (must meet both unless contraindicated): 1) Failure of a medium to ultra-high potency topical corticosteroid (see Appendix B); 2) Failure of one of: calcipotriene, calcitriol, or tazarotene
IL HIM bypass: Step therapy requirements do not apply for Illinois HIM requests on or after 1/1/2026 (IL HB 5395)

OpenPayer

Betamethasone Dipropionate Spray (Sernivo) — Coverage Criteria

Coverage Criteria

Coding and Limits

Provider Actions and Prior Authorization

Background

Definitions