ModifiedPremera BluecrossPolicy N/A

Pharmacologic Treatment of Psoriasis (including site-of-service review)

Medical necessity and site-of-service criteria for systemic, injectable, IV biologics, and select oral agents for plaque and other psoriasis subtypes affecting Premera plan members per formulary sections.

Policy Summary

PayerPremera Bluecross

PolicyPharmacologic Treatment of Psoriasis (including site-of-service review)

Policy CodePolicy N/A

Change TypeCoverage criteria and code updates (material additions/revisions)

Effective DateMar. 1, 2026

Next Review DateMar 10, 2026

Key ActionSubmit prior authorization with documentation of age, weight/BSA, prior systemic therapy trial/failure, and dermatologist prescriber or consult.

SourceLink

POLICY UPDATE CHANGES

Added coverage criteria for Otezla XR (apremilast extended release) for patients aged 6 years and older weighing at least 50 kg.

Added Otezla XR to list of preferred alternatives for Bimzelx, Siliq, Cosentyx, Cimzia, and Ilumya.

Updated Tremfya (guselkumab) coverage criteria to include individuals weighing at least 40 kg.

Added coverage for Spevigo (spesolimab-sbzo) for treatment of generalized pustular psoriasis flares in adults (historic addition referenced in policy history).

multiple biologics & oralslisted therapies

≥10% BSABSA threshold

6+/13+/18+age thresholds

≥1 systemicprior therapy requirement

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.

HCPCS/J updatescodes updated

Dermatologistdermatologist required

Coverage and Medical Necessity Criteria

Site of Service Medical Necessity (general)

Site of Service (SOS) Medical Necessity — general rules and scope for IV/injectable drugs.

SOS medical necessity criteria applies ONLY to medical benefit reviews; it does NOT apply to Medicare Advantage and does not apply to Alaska fully‑insured members (see member plan booklet or contact Customer Service).

We review specific intravenous (IV) and injectable drugs for medical necessity through the medical benefit. The following infliximab and spesolimab products are managed through the medical benefit and are subject to site‑of‑service review: Avsola (infliximab‑axxq), Inflectra (infliximab‑dyyb), Infliximab (Janssen unbranded), Remicade (infliximab), Renflexis (infliximab‑abda), and Spevigo (spesolimab‑sbzo).

For individuals aged 13 years and older, we will also review the site of service for medical necessity. Site of service is the location where a drug is administered (e.g., hospital‑based outpatient infusion department, infusion center, physician's office, or home infusion).

Medically necessary sites of service include: physician's office, infusion center, and home infusion (when a contracted home infusion agency will travel to the home).

Hospital‑based outpatient setting may be considered medically necessary for the first 90 days for: the initial course of infusion of a pharmacologic or biologic agent OR re‑initiation of an agent after 6 months or longer following discontinuation of therapy (this does not include agents with standard dosing intervals of 6 months or longer).

Hospital‑based outpatient setting may also be considered medically necessary when there is no outpatient infusion center within 50 miles of the individual's home and no contracted home infusion agency that will travel to the home, or when the hospital is the only place that offers infusions or injections of the drug.

Hospital‑based outpatient setting is considered medically necessary only when the individual has a clinical condition that increases the risk of complications for infusions or injections, including any one of the following: known cardiac condition (e.g., symptomatic cardiac arrhythmia) or significant respiratory disease (e.g., serious obstructive airway disease, %FVC ≤ 40%).

This policy does not address IV/injectable therapy for individuals receiving inpatient services.

Billing, HCPCS/Q/J Codes and Key Thresholds

Drugs subject to site-of-service review (select IV/injectables)mixed

Avsola (infliximab-axxq)	IV infliximab biosimilar
Inflectra (infliximab-dyyb)	IV infliximab biosimilar
Infliximab (Janssen - unbranded)	IV infliximab
Remicade (infliximab)	IV infliximab
Renflexis (infliximab-abda)	IV infliximab biosimilar
Spevigo (spesolimab-sbzo)	injectable biologic

Systemic biologics and oral agents (examples listed)mixed

Skyrizi (risankizumab-rzaa)	IL-23 inhibitor, SC
Taltz (ixekizumab)	IL-17 inhibitor, SC
Stelara (ustekinumab)	IL-12/23 inhibitor, SC
Steqeyma (ustekinumab-stba)	IL-12/23 inhibitor, SC (biosimilar/brand)
Yesintek (ustekinumab-kfce)	IL-12/23 inhibitor, SC (biosimilar/brand)
Tremfya (guselkumab)	IL-23 inhibitor, SC
Ilumya	IL-23 inhibitor, SC
Bimzelx	IL-17 inhibitor, SC
Cosentyx	IL-17 inhibitor, SC
Otezla (apremilast)	PDE4 inhibitor, oral

Listed medications by classmixed

Skyrizi (risankizumab-rzaa) SC	IL-23 inhibitor
Tremfya (guselkumab) SC	IL-23 inhibitor
Otezla (apremilast) oral / Otezla XR	PDE4 inhibitor
Sotyktu (deucravacitinib) oral	TYK2 inhibitor
Bimzelx (bimekizumab-bkzx) SC	IL-17 inhibitor
Taltz (ixekizumab) SC	IL-17 inhibitor
Cosentyx (secukinumab) SC	IL-17 inhibitor
Stelara / Steqeyma / Yesintek (ustekinumab variants) SC	IL-12/23 inhibitors
Ilumya (tildrakizumab-asmn) SC	IL-23 inhibitor
Avsola (infliximab-axxq) IV	Infliximab biosimilar

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Drugs subject to site-of-service review (selected list from document)mixed

Skyrizi	risankizumab-rzaa (SC) — IL-23 inhibitor
Taltz	ixekizumab (SC) — IL-17 inhibitor
Tremfya	guselkumab (SC) — IL-23 inhibitor
Stelara	ustekinumab (SC) — IL-12/23 inhibitor
Steqeyma	ustekinumab-stba (SC)
Yesintek	ustekinumab-kfce (SC)
Sotyktu	deucravacitinib (oral) — TYK2 inhibitor
Otezla	apremilast (oral) — PDE4 inhibitor
Otezla XR	apremilast extended-release (oral)
Avsola	infliximab-axxq (IV) — TNF-α inhibitor

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Named biologic agents in this sectionmixedCovered

Steqeyma (ustekinumab-stba)	listed biologic considered medically necessary per criteria
Yesintek (ustekinumab-kfce)	listed biologic considered medically necessary per criteria
Skyrizi (risankizumab-rzaa)	listed IL-23 inhibitor considered medically necessary per criteria
Tremfya (guselkumab)	listed IL-23 inhibitor considered medically necessary per criteria

Coding (not specified in excerpt)mixed

NDC/CPT/HCPCS not listed

No explicit billing or procedure codes present in this excerpt.

HCPCS/Codes for covered biologics and biosimilarsHCPCS

J0139	Injection, adalimumab, 1 mg
J0717	Injection, certolizumab pegol (Cimzia), 1 mg
J1438	Injection, etanercept (Enbrel), 25 mg
J1628	Injection, guselkumab (Tremfya), 1 mg
J1745	Injection, infliximab, excludes biosimilar, 10 mg
J2327	Injection, risankizumab-rzaa, IV (Skyrizi), 1 mg
J3245	Injection, tildrakizumab (Ilumya), 1 mg
J3357	Injection, ustekinumab (Stelara), 1 mg
J3590	Unclassified biologics (listed specific products)
Q5098	Injection, ustekinumab-srlf (Imuldosa), biosimilar, 1 mg

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HCPCS/Q codes for biologic injectionsHCPCS

Q5100	Injection, ustekinumab-kfce (Yesintek), biosimilar, 1 mg
Q5103	Injection, infliximab-dyyb, biosimilar, (Inflectra), 10 mg
Q5104	Injection, infliximab-abda, biosimilar, (Renflexis), 10 mg
Q5121	Injection, infliximab-axxq, biosimilar, (Avsola), 10 mg
Q5137	Injection, ustekinumab-auub (Wezlana), biosimilar, subcutaneous, 1 mg
Q5140	Injection, adalimumab-fkjp, biosimilar, 1 mg
Q5141	Injection, adalimumab-aaty, biosimilar, 1 mg
Q5142	Injection, adalimumab-ryvk biosimilar, 1 mg
Q5143	Injection, adalimumab-adbm, biosimilar, 1 mg
Q5144	Injection, adalimumab-aacf (Idacio), biosimilar, 1 mg

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Products and benefit assignmentmixed

N/A	List of products managed by medical, pharmacy, or both benefits (examples include Inflectra, Remicade, Avsola, Abrilada, Humira, Stelara, Tremfya, etc.)

Policy HCPCS/Q and J code updatesHCPCS

J3590	HCPCS code referenced for certain biologics (parentheticals updated)
J1747	New HCPCS code added
J2327	HCPCS code for Skyrizi
Q5098	Imuldosa (ustekinumab-srlf)
Q5099	Steqeyma (ustekinumab-stba)
Q5100	Yesintek (ustekinumab-kfce)
Q5137	Added HCPCS code (documented in history)
Q5140	Added HCPCS code
Q5141	Added HCPCS code
Q5142	Added HCPCS code

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inv-61: Body Surface Area (BSA) — common threshold >=10%

BSA threshold>= 10% body surface area

Common exceptionExceptions allowed for extensive recalcitrant facial involvement, pustular hands/feet, or genital involvement interfering with sexual function

ContextThreshold applies to determining moderate-to-severe chronic plaque psoriasis for many systemic/biologic agents

inv-63: Tremfya weight threshold — >= 40 kg

Weight requirement (Tremfya)

Prior Authorization, Documentation, and Denial Triggers

Billing Rule

Prior authorization and medical‑benefit processing

Prior authorization is required for many listed biologic and systemic dermatology agents. Claims for IV-administered drugs (infliximab products and others managed under the medical benefit) must be processed as medical benefit claims; site-of-service review may also apply and can render hospital outpatient billing non-medically necessary if site-of-service criteria are not met.

Prior authorization required for IV/injectable biologics and specified systemic agents.
IV-administered drugs billed as medical benefit; check HCPCS/Q codes in Coding section.
Site-of-service review applies to specified infliximab products (Avsola, Inflectra, Infliximab unbranded, Remicade, Renflexis) and select other agents.
Medically necessary sites: physician office, infusion center, home infusion (when covered), and hospital outpatient only in specific circumstances (initial course, re-initiation after ≥6 months, lack of local alternatives, or increased clinical risk).

Clinical Background and Evidence Summary

Psoriasis is an inflammatory skin disease characterized by red, scaly plaques that can affect any body surface. Management typically progresses from topical therapies to phototherapy and, for more extensive or refractory disease, systemic oral agents or biologic therapies. Biologics and systemic agents are considered when topical therapy is insufficient, disease is widespread (commonly defined as ≥10% body surface area for moderate-to-severe plaque psoriasis) or when special-site or pustular forms of disease require systemic treatment.

In addition to coverage logic for individual agents, this policy clarifies that uses of listed drugs outside the conditions and sequencing described — including concurrent use of multiple agents listed in this policy when not specified — are considered investigational. Requests for indications, combinations, or disease states not enumerated in the policy will be evaluated against available evidence and the policy’s exclusion of investigational uses.

Spesolimab has evidence supporting use in generalized pustular psoriasis (GPP) flares based on clinical trials showing rapid pustulation clearance; however, for palmoplantar pustulosis (PPP) the available Phase 2a trial (n=59, 16 weeks) did not demonstrate a significant difference versus placebo for the primary endpoint (PPPASI-50 at Week 16). The manufacturer is not currently pursuing FDA approval for the PPP indication, and the trial’s negative primary outcome limits support for coverage of spesolimab for PPP.

Definitions and Exception Criteria

inv-147: Site of Service (SOS) — definition of SOS and common locations

DefinitionSite of Service (SOS) — physical location where a drug is administered (physician office, infusion center, home infusion, hospital-based outpatient)

Medically necessary sitesPhysician's office, infusion center, home infusion (preferred medically necessary sites)

Hospital-based outpatientConsidered medically necessary for initial course or re-initiation (first 90 days) or when no outpatient/home infusion available or patient has clinical risk factors

inv-148: Plaque psoriasis — definition

DefinitionPlaque psoriasis — psoriasis subtype characterized by red, scaly plaques (plaques) often treated with topical therapies initially

Clinical context

Policy Changes and Updates

02/01/24step_therapy_update

Annual review added Bimzelx and updated various product listings and HCPCS usage; step therapy preferred-product trials were adjusted in multiple infliximab and adalimumab listings.

05/01/24coverage_addition

Added Spevigo (spesolimab-sbzo) SC injection coverage criteria and updated age requirement for Spevigo to 12 years or older.

07/01/24formulary_and_preferred_product_updates

Policy Summary

PayerPremera Bluecross

PolicyPharmacologic Treatment of Psoriasis (including site-of-service review)

Policy CodePolicy N/A

Change TypeCoverage criteria and code updates (material additions/revisions)

Effective DateMar. 1, 2026

Next Review DateMar 10, 2026

Key ActionSubmit prior authorization with documentation of age, weight/BSA, prior systemic therapy trial/failure, and dermatologist prescriber or consult.

SourceLink

On This Page

Minimum age>= 6 years (agent-specific)

Indication contextApplies to initial Tremfya (guselkumab) coverage for moderate-to-severe plaque psoriasis

inv-64: Otezla age/weight threshold — age >= 6 years and weight >= 20 kg

Age requirement (Otezla)>= 6 years

Weight requirement (Otezla)>= 20 kg

Formulation notesOtezla XR has a different (higher) weight threshold; see Otezla XR entry

inv-65: Otezla XR weight threshold — weight >= 50 kg

Weight requirement (Otezla XR)>= 50 kg

Age requirement>= 6 years

IndicationOtezla XR (apremilast extended-release) coverage for moderate-to-severe plaque psoriasis

inv-72: Required prior systemic therapy count — >= 1

Required prior systemic therapy count>= 1 adequate trial and treatment failure with an approved systemic therapy (e.g., methotrexate, cyclosporine, acitretin, PUVA)

ExceptionsNot required if contraindicated or not tolerated

DocumentationChart must document prior trial and treatment failure or contraindication/intolerance

inv-73: Minimum age and weight — Age >= 6 years; Weight >= 40 kg

Minimum age>= 6 years

Minimum weight>= 40 kg

ContextApplies to initial Tremfya (guselkumab) eligibility and similar agent-specific pediatric criteria

inv-74: Disease severity threshold — Chronic plaque psoriasis involving >= 10% BSA (exceptions allowed for specific site involvement)

Disease severity threshold>= 10% body surface area (BSA)

Special-site exceptionsExceptions allowed for extensive recalcitrant facial involvement, pustular involvement of hands/feet, or genital involvement interfering with sexual function

ApplicabilityUsed to define moderate-to-severe chronic plaque psoriasis for systemic/biologic coverage determinations

inv-82: GPPGA pustulation subscore for trial entry — >= 2

GPPGA pustulation subscore>= 2

Use caseEligibility criterion for inclusion in spesolimab GPP flare trials and acute GPP flare coverage considerations

Additional requirement>=5% BSA involvement typically required for trial entry (see related GPP criteria)

inv-83: Body surface area for GPP trial entry — >= 5% BSA

GPP trial BSA requirement>= 5% body surface area (BSA)

ContextUsed alongside GPPGA pustulation subscore for defining moderate-to-severe GPP flare in trial inclusion

Trial linkageBased on EFFISAYIL 1 trial inclusion criteria for spesolimab

inv-85: Otezla XR weight requirement — >= 50 kg

Otezla XR weight requirement>= 50 kg

Minimum age>= 6 years

Policy changeOtezla XR criteria added in 2026 update (effective dates noted in history)

inv-86: Tremfya weight requirement — >= 40 kg

Tremfya weight requirement>= 40 kg

Minimum age>= 6 years (agent-specific)

Policy noteTremfya coverage criteria updated to include the >=40 kg weight threshold in 2026 update

Prior Authorization

Prior authorization / site‑of‑service review required

Prior authorization and site-of-service review are required for many agents listed in this policy. For infliximab products, site-of-service review is specifically applied and may require demonstration that administration at a hospital outpatient setting meets the limited medical necessity exceptions.

Avsola (infliximab-axxq) and Inflectra (infliximab-dyyb) are subject to site‑of‑service review.
Infliximab (Janssen unbranded), Remicade, and Renflexis are subject to site‑of‑service review.
Documentation must support the medical necessity of the chosen site of service (see medically necessary site list and exceptions).

Documentation Required

Prior authorization requirement

Prior authorization approvals are granted only when all applicable criteria are met. Typical requirements include patient age and disease extent (commonly ≥10% BSA for adults or specific pediatric criteria), prior systemic therapy trial(s) or documented contraindication/intolerance, and that the medication is prescribed by or in consultation with a dermatologist.

Document patient age and weight when required by the drug-specific criteria (examples: Tremfya age ≥6 years and weight ≥40 kg; Otezla/Otezla XR pediatric weight thresholds).
Percent BSA affected (commonly ≥10% for adults) or a qualifying exception (extensive facial, pustular hands/feet, or genital involvement interfering with function).
Prescriber specialty: medication must be prescribed by or in consultation with a dermatologist; requests without dermatologist involvement may be denied.
Prior systemic therapy: evidence of at least one adequate trial and treatment failure with an approved systemic therapy (e.g., methotrexate, cyclosporine, acitretin, or PUVA) unless contraindicated/intolerant.

Documentation Required

Prior authorization requirements and documentation expectations

Prior authorization requires submission of supporting clinical documentation. Expect documentation of diagnosis (chronic plaque psoriasis), percent BSA or qualifying exception, prior trial(s) including durations and outcomes, prescriber specialty or consultation notes, and any contraindications/intolerances that waive prior therapy requirements.

Required clinical documentation: diagnosis, BSA affected, prior adequate trial(s) with dates, reason for treatment change or failure, and dermatologist notes/consultation.
Prior trial documentation should explicitly list agents tried (including biosimilars where required), doses, duration, and reason for discontinuation (inefficacy, intolerance, or contraindication).
Missing or incomplete prior therapy documentation (e.g., no record of required systemic therapy trial) is a common trigger for denial.
Requests may be approved up to 12 months for initial or non‑formulary exception reviews when criteria and documentation support continuation (see Length of Approval).

Step Therapy

Step therapy, prior biologic trials, and sequencing requirements

Step therapy and sequencing rules apply: many agents are designated first‑ or second‑line and require inadequate response or intolerance to specified first‑line agents; several agents require prior biologic or specific preferred agent trials before approval.

Step therapy tiers determine required prior agents; review drug‑specific criteria for required first‑line and second‑line failures.
Examples: some IL‑23 and IL‑17 inhibitors require prior inadequate response or intolerance to specified TNF antagonists, apremilast, or other named biologics.
Prior biologic trials and sequencing (including trials of preferred biosimilars) are enforced per the policy; failure to document required sequencing may lead to denial.

Step Therapy

Infliximab biosimilar trial requirement

Infliximab biosimilar trial requirement: for some infliximab products, a documented trial and treatment failure with specified infliximab biosimilars (Avsola and Inflectra) is required prior to coverage of other infliximab products.

For individuals not previously treated with the requested infliximab therapy, documentation of trial and treatment failure with Avsola (infliximab‑axxq) AND Inflectra (infliximab‑dyyb) is required before coverage of certain infliximab products.
Renflexis may require documented trials/failures with Avsola and Inflectra prior to approval.
Ensure prior therapy records specify biosimilar product name, dates, dosing, and reason for failure.

Denial Risk

Potential denial triggers and required conditions

Potential denial triggers include lack of prior authorization, insufficient or missing documentation of required prior systemic or biosimilar trials, absence of dermatologist prescribing/consultation, and inappropriate site‑of‑service billing when site criteria are unmet.

Claims for IV‑administered drugs must be billed to the medical benefit; billing to hospital outpatient without meeting site‑of‑service exceptions may be denied.
Requests lacking evidence of required prior systemic therapy or required biosimilar trials can be denied.
Requests not prescribed by or in consultation with a dermatologist may be denied.
Site‑of‑service denials can occur when administration is requested in a non‑preferred setting without meeting the listed exceptions (initial course, re‑initiation after ≥6 months, lack of local alternatives, or elevated clinical risk).

May progress to require phototherapy, systemic oral agents, or biologics when widespread or refractory

Policy useUsed throughout policy to define indications for systemic/biologic therapies

inv-149: Moderate to severe plaque psoriasis — policy definition (>=10% BSA with exceptions)

Policy definition>= 10% body surface area (BSA) involvement defines moderate-to-severe plaque psoriasis

ExceptionsExceptions allowed for extensive recalcitrant facial involvement, pustular hands/feet, or genital involvement interfering with sexual function

ApplicationThreshold applied to determine medical necessity for systemic/biologic therapy across multiple plan sections

inv-151: Special-site exception — Special-site involvement (facial, genital, pustular hands/feet) may allow exceptions to BSA threshold

Special-site exceptionExtensive recalcitrant facial involvement, pustular involvement of hands/feet, or genital involvement interfering with sexual function may permit coverage despite <10% BSA

UsageApplied when disease in these anatomic sites significantly impairs function or is refractory to local therapy

DocumentationClinical documentation must support extent and recalcitrance of special-site disease

inv-152: Exception for treatment despite <10% BSA — extensive recalcitrant facial involvement, pustular hands/feet, or genital involvement interfering with sexual function

Allowed exceptionsExtensive recalcitrant facial involvement OR pustular involvement of hands/feet OR genital involvement interfering with sexual function

Coverage implicationMay allow treatment despite total BSA <10% when documented and severe

Documentation requirementProvider must document the specific site involvement and impact on function or refractoriness to prior therapies

inv-153: Approved systemic therapy — examples include methotrexate, cyclosporine, acitretin, PUVA

ExamplesApproved systemic therapy examples include methotrexate, cyclosporine, acitretin, or psoralen plus ultraviolet A (PUVA)

RoleAt least one adequate trial and treatment failure with an approved systemic therapy is commonly required prior to biologic coverage

ExceptionNot required if contraindicated or not tolerated; documentation must support this

inv-154: Dermatologist involvement — medication must be prescribed by or in consultation with a dermatologist for coverage under named plans

Prescriber requirementMedication must be prescribed by or in consultation with a dermatologist

ApplicabilityRequirement repeated across agent- and plan-specific sections for coverage under named plans

DocumentationRequests should include evidence of dermatologist involvement in chart notes or referral/consultation

inv-162: Site-of-service age limit — For SOS medical necessity review the age criterion is 13 years or older

SOS age limitAge >= 13 years for site-of-service medical necessity review

RationalePediatric infusion considerations: physiologic, equipment, and behavioral factors require specialty infusion training for younger children

ScopeSite-of-service review limited to individuals above age 13; pediatric infusion considerations apply for those under 13

inv-164: GPP definition — Generalized pustular psoriasis definition and implications

GPP definitionGeneralized pustular psoriasis (GPP) — sterile, visible pustules on non-acral skin that can occur with systemic inflammation and may be life-threatening

Clinical courseGPP can cause systemic symptoms and relapsing/remitting flares; trial eligibility may require specific pustulation subscores and BSA involvement

Policy implicationAcute GPP flares may be eligible for spesolimab under trial-like criteria (GPPGA pustulation subscore and BSA thresholds)

inv-165: PPP definition — Palmoplantar pustulosis definition and associated factors

PPP definitionPalmoplantar pustulosis (PPP) — persistent sterile pustules on palms and soles; chronic relapsing course, associated with tobacco and oral infections

Evidence noteSpesolimab Phase 2a PPP trial did not meet primary endpoint (PPPASI-50 at Week 16), limiting support for PPP indication

Policy implicationSpesolimab is not being pursued for FDA approval for PPP per document; PPP use lacks demonstrated efficacy in cited trial

Updated preferred Humira biosimilars and adjusted preferred/non-preferred adalimumab product listings used in step-therapy prerequisites.

05/01/25re-authorization_change

Updated re-authorization duration of approvals from 3 years to 12 months (affects step therapy and preferred-agent trial planning).

03/01/26material_additionLatest

Policy history records that step therapy requirements and preferred vs non-preferred listings (including addition of Otezla XR to preferred alternatives) are tracked and updated in history; step therapy and preferred-agent trial changes noted across history entries.

02/01/25hcpcs_update

Added new HCPCS codes J0139, Q5140, Q5141, Q5142, Q5143, Q5144, Q5145 recorded in policy history.

07/01/25hcpcs_additions

Added multiple ustekinumab-related HCPCS/Q codes (Q5098, Q5099, Q5100, Q5137, Q9996, Q9998, Q9999) and other code updates; clarified effective dates for some codes.

08/01/25hcpcs_addition

Added HCPCS code J2327 for Skyrizi to the policy history (missed during 2023 update).

03/01/26hcpcs_and_code_updatesLatest

Added and documented additional HCPCS/Q and J-code updates (including parenthetical additions to J3590 and Starjemza inclusion) in policy history entries through early 2026.

11/01/22coverage_addition

Added coverage for Spevigo (spesolimab-sbzo) for treatment of generalized pustular psoriasis flares in adults and recorded in policy history.

05/01/24coverage_update

Added Spevigo SC injection coverage criteria and updated age requirement for Spevigo to 12 years or older in the policy history.

07/01/25criteria_clarification

Updated Stelara coverage criteria to require trial with new ustekinumab biosimilars for individuals not previously treated; multiple policy sections clarified spesolimab placement in history and site-of-service remarks.

03/01/26historic_referenceLatest

Policy history explicitly documents addition of coverage for spesolimab (Spevigo) and records related site-of-service and criteria notes across history entries through 2026.