CurrentEmblemHealthPolicy MG.MM.PH.367

Spevigo (spesolimab-sbzo), Intravenous Infusion and Subcutaneous

Defines EmblemHealth coverage criteria, dosing limits, and documentation requirements for intravenous and subcutaneous Spevigo in treating generalized pustular psoriasis (GPP) in members, including age/weight limits and renewal restrictions.

Policy Summary

PayerEmblemHealth

PolicySpevigo (spesolimab-sbzo), Intravenous Infusion and Subcutaneous

Policy CodePolicy MG.MM.PH.367

Key ActionSubmit prior authorization with clinical evidence of age, weight, GPPGA total score and pustulation subscore, BSA involved, flare history, and prescribing provider specialty or dermatology consultation.

Change TypeMaterial revisions to IV pathway, renewal language, and exclusions

Effective DateNov 10, 2022

Next Review DateFeb 13, 2025

SourceLink

POLICY UPDATE CHANGES

Added alternative pathway for IV dosing when patient is currently receiving Spevigo subcutaneous with specific GPPGA score increase and pustulation subscore criteria.

Renewal criteria clarified to specify 'for the treatment of generalized pustular psoriasis' in the statement about not using concurrent biologics or non-biologic agents.

Removed prohibition language that the patient will not use concomitantly with systemic immunosuppressants or other topical agents (examples listed).

≥ 12 yearsminimum age for coverage

≥ 40 kgminimum weight for coverage

up to 2IV loading doses allowed

600 mg x1SC loading dose allowed

L40.1diagnosis code for GPP

Coverage Criteria for Spevigo (spesolimab-sbzo)

Intravenous Loading dose

Intravenous loading dose covered when ALL of the following are met:

ALL of the following

Patient is ≥ 12 years of age and weighs at least 40 kg (88 lbs).
Disease activity
- i
  - Patient is NOT currently receiving Spevigo subcutaneous and meets ALL of the following:
  - GPPGA total score ≥ 3 points.

Policy Summary

PayerEmblemHealth

PolicySpevigo (spesolimab-sbzo), Intravenous Infusion and Subcutaneous

Policy CodePolicy MG.MM.PH.367

Change TypeMaterial revisions to IV pathway, renewal language, and exclusions

Effective DateNov 10, 2022

Next Review DateFeb 13, 2025

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.

Subcutaneous Loading Dose

Subcutaneous loading dose covered when ALL of the following are met (for patients not currently experiencing a moderate-to-severe flare):

ALL of the following

Patient is ≥ 12 years of age.
Patient weighs ≥ 40 kilograms (kg).
Patient has a history of at least two generalized pustular psoriasis flares of moderate-to-severe intensity in the past.
GPPGA total score of 0 or 1 at baseline.
Prior therapy
- i
  - Patient has had a 4-month trial of at least one treatment for generalized pustular psoriasis (examples include methotrexate, acitretin, cyclosporine, or biologics).
  - Patient has a history of flaring while on treatment or with dose reduction or discontinuation of treatment.
- ii
  - Patient tried at least one treatment for generalized pustular psoriasis but was unable to tolerate a 4-month trial.
Medication is prescribed by or in consultation with a dermatologist.
Dose limits: SC — 600 mg (four 150 mg injections) on day 0.

Coding: HCPCS, NDC, and Diagnosis Codes

Applicable HCPCS CodesHCPCSCovered

J1747

Injection, spesolimab-sbzo, 1mg

Applicable NDCsNDCCovered

00597-0035-10	Spevigo (spesolimab-sbzo) 60mg/mL (7.5mL vial)
00597-0620-xx	Spevigo 150 mg/mL two-pack single-dose pre-filled syringe for subcutaneous use

Applicable ICD-10 DiagnosesICD-10Covered

L40.1

Generalized pustular psoriasis

inv-08: GPPGA total score (flare) — threshold used in policy

Policy thresholdGPPGA total score ≥ 3 for an active moderate-to-severe flare

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

Context of useRequired when patient is NOT currently receiving Spevigo subcutaneous and meeting IV loading criteria

inv-09: GPPGA pustulation subscore — threshold used for IV approval in flares

Policy thresholdGPPGA pustulation subscore ≥ 2 required for IV approval in flares

RoleAssesses pustulation severity as part of IV loading dose criteria

Applied in both pathwaysRequired whether patient is on SC Spevigo (with additional total-score increase requirement) or not on SC

inv-10: Increase in GPPGA total score (on treatment) — threshold for alternative IV pathway

Policy thresholdIncrease in GPPGA total score ≥ 2 (while on treatment) — required alternative IV pathway for patients currently receiving SC Spevigo

Used with pustulation subscoreThis ≥2 increase must be accompanied by a GPPGA pustulation subscore ≥2

ContextApplies when patient IS currently receiving Spevigo subcutaneous and experiencing worsening disease

Provider Actions, Documentation & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for Spevigo (spesolimab-sbzo). Submit clinical documentation supporting the request; failure to provide required information will prevent proper review of the preauthorization or renewal.

Procedure code: HCPCS J1747 (Injection, spesolimab-sbzo, 1 mg).
Max dosing limits: IV loading dose — two 900 mg doses (day 1 and day 8). SC loading dose — one 600 mg dose (four 150 mg injections) x 1 dose only.
If documentation is incomplete the request may be denied or pended for additional information.

Documentation Required

Documentation Required for Review

The reviewer must receive sufficient clinical documentation to determine medical necessity. Without this information EmblemHealth will not be able to properly review the request.

Age and weight of the patient (must meet age/weight thresholds for IV or SC dosing).
Diagnosis and disease characteristics (including presence/absence of plaque psoriasis).
Treatment history and prior therapies (including dates, doses, responses, and intolerance).
Number and timing of prior generalized pustular psoriasis (GPP) flares.
Current and baseline Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) total score and pustulation subscore, and body surface area (%) affected.
If already receiving spesolimab, dates and number of prior doses and response to therapy.

Step Therapy

Subcutaneous Trial/Step Requirement

For subcutaneous (SC) loading dose requests, document that the patient meets the step/trial requirements prior to approval when not presenting in a current moderate-to-severe flare.

SC Loading Dose criteria: patient ≥ 12 years and ≥ 40 kg; history of at least two GPP flares of moderate-to-severe intensity; current GPPGA total score of 0 or 1; AND either (a) a 4-month trial of at least one systemic treatment for GPP (e.g., methotrexate, acitretin, cyclosporine, or biologics) with history of flaring on treatment or with dose reduction/discontinuation, or (b) documentation of intolerance to at least one such treatment preventing a 4-month trial.
Prescriber requirement: prescribed by or in consultation with a dermatologist.

Denial Risk

Concomitant Therapy and Exclusion Risks

Concurrent therapies and certain diagnosis features may preclude approval or renewal. Verify and document concurrent medications and comorbid psoriasis subtypes.

Intravenous use: patient must NOT be on concurrent TNF-inhibitor, biologic response modifier, or other non-biologic agents for GPP (examples: apremilast, tofacitinib, baricitinib, upadacitinib).
Subcutaneous use: concomitant use with another biologic or DMARD prescribed for GPP is not permitted.
Presence of plaque psoriasis is an exclusion for coverage; document whether plaque psoriasis is present or absent.
If the patient is currently receiving Spevigo SC, document objective evidence of worsening (increase in GPPGA total score ≥ 2 points and pustulation subscore ≥ 2) if requesting IV dosing for a flare.

Definitions and Scoring

inv-17: GPPGA total score definition and thresholds used in policy

DefinitionGPPGA total score (Generalized Pustular Psoriasis Physician Global Assessment) rates overall disease from 0 (clear) to 4 (severe)

Flare threshold (IV approval)GPPGA total score ≥ 3 indicates a moderate-to-severe flare and is required for IV loading when not on SC therapy

Worsening-on-treatment thresholdAn increase in GPPGA total score of ≥ 2 while on treatment qualifies for the alternative IV pathway when combined with pustulation subscore ≥2

inv-18: GPPGA pustulation subscore definition and threshold for IV approval in flares

DefinitionGPPGA pustulation subscore assesses severity of pustulation within the GPPGA framework

IV approval thresholdPustulation subscore ≥ 2 is required for IV loading-dose approval during flares

Combined requirementWhen on SC Spevigo, pustulation subscore ≥2 must accompany an increase in GPPGA total score ≥2 for IV approval

OpenPayer

Spevigo (spesolimab-sbzo), Intravenous Infusion and Subcutaneous

Coverage Criteria for Spevigo (spesolimab-sbzo)

Coding: HCPCS, NDC, and Diagnosis Codes

Provider Actions, Documentation & Prior Authorization

Background

Definitions and Scoring