ModifiedmhnPolicy CP.PMN.182

Betamethasone Dipropionate Spray (Sernivo) coverage

Defines medical necessity and prior authorization criteria for Sernivo topical spray for adults with mild to moderate plaque psoriasis under the payer's lines of business.

Policy Summary

Payermhn

PolicyBetamethasone Dipropionate Spray (Sernivo) coverage

Policy CodePolicy CP.PMN.182

Change TypeMaterial — step therapy bypass added

Effective DateDec 1, 2018

Next Review Date

Key ActionObtain prior authorization with documentation showing diagnosis, age ≥18, required topical therapy failures (unless contraindicated), and dosing ≤120 mL per 4 weeks.

SourceLink

POLICY UPDATE CHANGES

Step therapy bypass for Illinois HIM requests was added per IL HB 5395.

18+minimum age for FDA indication and coverage

120 mLmaximum authorized dose per 4 weeks

1 monthtypical approval duration

0.05%product strength

state-specificMedicaid precedence

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Coverage Criteria

Initial Therapy

Covered when ALL of the following are met:

Initial Approval - Plaque Psoriasis: 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, the 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, the 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.N/A

Approval duration: 1 month

Continuation Therapy

Covered when ALL of the following are met:

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

Approval duration: Up to 1 month of total treatment (a single continuous course of therapy up to 4 weeks is recommended)

Other/Off-label Uses

If requested use is not covered under main sections:

Other Indications/Off-label Uses: 1. If the drug has undergone a label change within the last 6 months that is not yet reflected in this policy, follow one of: (a) for drugs on the formulary/PDL, apply the no coverage criteria policy for the relevant line of business (CP.CPA.190 for commercial, HIM.PA.33 for marketplace, CP.PMN.255 for Medicaid); or (b) for drugs not on the formulary/PDL, apply the non-formulary policy for the relevant line of business (CP.CPA.190 for commercial, HIM.PA.103 for marketplace, CP.PMN.16 for Medicaid); 2. If the requested use (diagnosis, age, dosing) is not listed under section III and criterion 1 does not apply, refer to the off-label use policy for the relevant line of business (CP.CPA.09 for commercial, HIM.PA.154 for marketplace, CP.PMN.53 for Medicaid).N/A

See referenced policies for formulary and off-label handling

Non‑FDA approved indications that are not specifically addressed in this policy are not authorized unless the provider submits sufficient documentation demonstrating efficacy and safety in accordance with the applicable off‑label use policy for the member’s line of business (see CP.CPA.09 for commercial, HIM.PA.154 for Health Insurance Marketplace, and CP.PMN.53 for Medicaid) or unless evidence of coverage documentation supports the request.

When coverage provisions in this clinical policy conflict with state Medicaid coverage requirements, the state Medicaid coverage provisions take precedence. Providers should refer to the applicable state Medicaid manual for state‑specific coverage rules that supersede this policy.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization requires documentation of diagnosis, age ≥18, prior failures of required topical therapies (unless contraindicated), and that dose does not exceed 120 mL every 4 weeks. Provider must submit documentation (such as office chart notes, lab results, or other clinical information) supporting that the member has met all approval criteria. Requests lacking required supporting documentation or seeking coverage for non‑FDA indications without sufficient off‑label evidence (per CP.CPA.09, HIM.PA.154, CP.PMN.53 or applicable evidence of coverage documents) may be denied.

Dose limit: ≤ 120 mL every 4 weeks
Initial approval requires: diagnosis of plaque psoriasis, age ≥18, failure of a medium to ultra‑high potency topical corticosteroid (unless contraindicated), and failure of one of calcipotriene, calcitriol, or tazarotene
For Illinois HIM requests: step therapy requirements do not apply as of 1/1/2026 per IL HB 5395

Documentation Required

Supportive Documentation Required

Affected Codes

Affected codesmixed

affected codes

Placeholder in this document indicating specific codes are governed by prior authorization and coverage terms referenced elsewhere

Definitions

PsO — Plaque psoriasis (abbreviated PsO in the document).

DefinitionPlaque psoriasis (abbreviated PsO)

Abbreviation key locationAppendix A: Abbreviation/Acronym Key

Acronym expansionPsO = plaque psoriasis

Background

Sernivo (betamethasone dipropionate 0.05% spray) is a topical corticosteroid indicated for the treatment of mild to moderate plaque psoriasis in adults. The product is formulated as a 0.05% spray and dosing guidance aligns with the FDA label and this policy: typically applied twice daily for up to 4 weeks with a maximum authorized quantity of 120 mL per 4 weeks, and avoidance of application to intertriginous sites. Coverage under this policy is aligned to the FDA indication and requires meeting the policy’s age and prior‑therapy criteria.

Policy Summary

Payermhn

PolicyBetamethasone Dipropionate Spray (Sernivo) coverage

Policy CodePolicy CP.PMN.182

Change TypeMaterial — step therapy bypass added

Effective DateDec 1, 2018

Next Review Date

Key ActionObtain prior authorization with documentation showing diagnosis, age ≥18, required topical therapy failures (unless contraindicated), and dosing ≤120 mL per 4 weeks.

SourceLink

On This Page

Provider must submit supporting documentation (e.g., office chart notes, lab results, or other clinical information) demonstrating that the member meets ALL approval criteria. Requests lacking documentation that the member meets all approval criteria, or that request treatments for non‑FDA indications without supporting off‑label evidence or applicable prior authorization policies, may be denied.

Examples of acceptable documentation: relevant office notes, prior treatment records, allergy/intolerance documentation, and lab or pathology reports where applicable
Missing documentation may result in denial or delay of prior authorization

Step Therapy

Step Therapy Requirements and IL Exception

Step therapy requires failure of a medium to ultra‑high potency topical corticosteroid (see Appendix B) and failure of one of calcipotriene, calcitriol, or tazarotene, unless contraindicated or clinically significant adverse effects are experienced. For Illinois Health Insurance Marketplace (HIM) requests, these step therapy requirements do not apply beginning 1/1/2026 per IL HB 5395. The 4Q2025 annual review added a specific step therapy bypass for IL HIM per IL HB 5395.

Step therapy bypass for IL HIM effective 01/01/2026 per IL HB 5395
Reference: 4Q 2025 annual review — added step therapy bypass for IL HIM

Note

Coverage and Claims Submission Reminder

Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions, and limitations of the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance), as well as state and federal requirements and applicable Health Plan administrative policies and procedures. Providers must follow member coverage documents and state/federal requirements when submitting claims; documentation should support medical necessity for adjudication.

Coverage is subject to the member's plan terms and applicable law
Providers should verify member benefits and obtain prior authorization when required