CurrentCignaPolicy IP0501

Spevigo Intravenous Prior Authorization Policy

Defines Cigna's prior authorization, coverage criteria, dosing, and coding for Spevigo IV for treatment of generalized pustular psoriasis flares in patients meeting age/weight and clinical severity requirements.

Policy Summary

PayerCigna

PolicySpevigo Intravenous Prior Authorization Policy

Policy CodePolicy IP0501

Change TypeRevised — material changes

Effective DateMay 15, 2025

Next Review DateMay 15, 2026

Key ActionSubmit prior authorization documenting age, weight, GPPGA total and pustulation subscores, BSA and prior Spevigo use; prescriber must be or consult a dermatologist.

SourceLink

POLICY UPDATE CHANGES

Policy title updated and authorization language added; age requirement changed from ≥18 to ≥12 years and weight requirement of ≥40 kg was added.

900 mgsingle IV dose

2max doses per flare

≥12 yrsmin age

≥40 kgmin weight

30 days

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.

Coverage Criteria for Spevigo (spesolimab-sbzo) IV

FDA-Approved Indication (Generalized Pustular Psoriasis Flare)

Approve for up to two doses if the patient meets ALL of the following (A through F):

Approval criteria for Spevigo IV

A/B/C: A) Patient is >= 12 years of age; AND B) Patient weighs >= 40 kilograms; AND C) Patient is experiencing a flare of moderate-to-severe intensity;
D: Clinical severity requirement
- D.i - Not currently receiving Spevigo SC: Patient is not currently receiving Spevigo subcutaneous injection and meets ALL of the following: a) GPPGA total score >= 3; b) GPPGA pustulation subscore >= 2; c) new or worsening pustules; d) erythema and pustules affecting >= 5% body surface area.
- D.ii - Currently receiving Spevigo SC: Patient is currently receiving Spevigo subcutaneous injection and meets BOTH of the following: a) increase in GPPGA total score >= 2 points; AND b) GPPGA pustulation subscore >= 2 points.
E: If patient has already received Spevigo intravenous, patient meets BOTH of the following: i) has not already received two doses of Spevigo IV for the current flare; AND ii) if patient previously received two doses, at least 12 weeks have elapsed since the last dose.
F: Medication is prescribed by or in consultation with a dermatologist.

ref

title

ref

Spevigo (spesolimab‑sbzo) intravenous infusion is not medically necessary for uses outside the approved indication of treatment of generalized pustular psoriasis flares. Specifically, Spevigo IV for plaque psoriasis without generalized pustular psoriasis is considered not medically necessary because the drug has not been studied in that population. (Patients who have both plaque psoriasis and generalized pustular psoriasis should be evaluated under the generalized pustular psoriasis criteria.)

Spevigo IV is not medically necessary when given concomitantly with another biologic prescribed for treatment of generalized pustular psoriasis. Although some biologics approved for plaque psoriasis have been used off‑label in case reports, pivotal trials required discontinuation of other biologic therapy before initiating Spevigo. This list is not all‑inclusive and may be updated as new data become available.

Initial Therapy — Criteria for First IV Dose

Continuation Therapy — Criteria for Additional/Extended Dosing

Coding and Clinical Thresholds

Considered Medically Necessary HCPCS CodesHCPCSCovered

J1747

Injection, spesolimab-sbzo, 1 mg (Code effective 04/01/2023)

GPPGA total score — requirement

GPPGA total score requirement>= 3 points (required for patients not currently receiving Spevigo SC as part of initial IV approval pathway)

Context in approval logicPart of criterion D.i(a): required along with pustulation subscore >=2, new/worsening pustules, and >=5% BSA involvement

Scale referenceGPPGA total score ranges from 0 (clear) to 4 (severe)

GPPGA pustulation subscore — requirement

GPPGA pustulation subscore requirement>= 2 points

Role in approval scenariosRequired for both D.i (patients not on Spevigo SC) and D.ii (patients currently receiving Spevigo SC) pathways

Provider Actions, Documentation, and Denials

Prior Authorization

Prior Authorization Required

Prior authorization required for IV Spevigo. Approvals are provided for 1 month (30 days); extended approvals allowed if patient continues to meet criteria. Spevigo must be prescribed by or in consultation with a physician who specializes in the condition being treated (dermatologist). Requests for doses outside the dosing in this policy are reviewed case-by-case by a clinician.

All approvals: 1 month (30 days)
Prescriber requirement: dermatologist or in consultation with dermatologist
Out-of-policy dosing: case-by-case review

Documentation Required

Required Documentation for Prior Authorization

Provider must document patient age and weight, GPPGA total score and pustulation subscore, presence of new or worsening pustules, body surface area affected, prior Spevigo IV dosing history (number of doses and dates), and that criteria for dosing interval have been met (e.g., ≥12 weeks since last IV for a new flare). Include evidence the patient meets moderate-to-severe flare definition per policy.

Quantity Limits and Site-of-Care

Spevigo IV — quantity limits

Quantity limit per flareUp to 2 doses of Spevigo (spesolimab‑sbzo) IV per flare

Dose sizeEach dose is 900 mg administered by IV infusion

Dosing intervalIf a second dose is given, 7 days must elapse between doses; if patient previously received two IV doses for the current flare, at least 12 weeks must elapse before retreatment

Billing Rule

Infusion center (site‑of‑care requirement)

Spevigo IV must be administered by a healthcare professional in a healthcare setting (IV infusion site-of-care requirement).

Definitions and Scoring

GPPGA total score — definition

GPPGA total score — definitionRanges from 0 (clear) to 4 (severe)

Use in policyUsed to determine eligibility for Spevigo IV in the initial-therapy pathway (GPPGA >=3 required for D.i)

Numeric scale implicationHigher scores indicate more severe disease; policy uses threshold of >=3 to define moderate-to-severe flares

GPPGA pustulation subscore — definition and role

GPPGA pustulation subscore — definitionA subscore within the GPPGA to quantify pustulation

Role in approvalPolicy requires pustulation subscore >=2 for approval in both D.i (not on SC) and D.ii (on SC) scenarios

Step Therapy Guidance

Line	Recommended therapies (guideline examples)
First-line	Acitretin; cyclosporine; methotrexate; infliximab
Second-line	Adalimumab (Humira); etanercept (Enbrel); topical therapies (e.g., corticosteroids, calcipotriene, tacrolimus); PUVA (psoralen and ultraviolet A)

Background

Spevigo (spesolimab‑sbzo) is an interleukin‑36 receptor antagonist indicated for the treatment of generalized pustular psoriasis flares. It is approved for use in patients aged ≥ 12 years who weigh ≥ 40 kg. Administration is by intravenous infusion (single 900 mg dose given over 90 minutes) in a healthcare setting by a trained professional; a second 900 mg IV dose may be given 7 days after the first if clinically indicated, with up to 2 doses per flare permitted under the coverage criteria.