Obtain prior authorization and limit IV dosing/authorization period

Prior authorization is required. Submit documentation showing the diagnosis of generalized pustular psoriasis (GPP) and that the patient meets the policy's clinical criteria for the requested regimen. For intravenous (IV) treatment of a single GPP flare, authorization will be for no more than 21 days and total IV doses must not exceed two doses per single GPP flare.

• Authorization limited to ≤2 IV doses per single GPP flare; a new separate flare may be treated with up to two doses.
• IV authorization duration: no more than 21 days.
• Prescribed by a dermatologist as required by the policy.

Confirm FDA indication and age/weight eligibility in prior authorization

For prior authorization, verify the FDA‑indicated diagnosis (GPP) and confirm patient meets age and weight criteria. Spevigo is indicated for adults and pediatric patients ≥12 years old who weigh ≥40 kg; include this information in the request and ensure the request aligns with the benefit plan.

• Document FDA‑indicated diagnosis: generalized pustular psoriasis (GPP).
• Document patient is ≥12 years of age and ≥40 kg when pediatric.
• For subcutaneous (SC) use, include prescriber attestation as specified (e.g., inability to self‑administer if applicable) and intended administration regimen (loading dose vs maintenance).

Do not use Spevigo with another targeted immunomodulator

Do not prescribe Spevigo in combination with another targeted immunomodulator for the same indication; the policy requires monotherapy for the indication and the prescriber must attest the patient is not receiving concurrent targeted agents.

• Examples of targeted immunomodulators listed include etanercept, certolizumab, golimumab, abatacept, adalimumab, tofacitinib, baricitinib, upadacitinib, ustekinumab, risankizumab.
• No additional step‑therapy sequencing is mandated in the policy text, but combination therapy is expressly prohibited.

Document features that distinguish GPP from plaque psoriasis

Differentiate GPP from plaque psoriasis when documenting diagnosis: GPP requires primary sterile pustules on an erythematous base not restricted to acral regions or within psoriatic plaques. Trials excluded plaque psoriasis without pustules or with pustules restricted to plaques, so documentation must reflect GPP rather than plaque psoriasis.

• Record that pustules are primary, sterile, macroscopically visible on an erythematous base and are not confined to acral areas or within psoriatic plaques.
• Reference relevant consensus definitions or trial exclusion criteria where helpful to support differentiation.

Submit detailed diagnostic documentation of pustules and distribution

Provide diagnostic documentation demonstrating primary sterile pustules on an erythematous base and that pustulation is not restricted to acral regions or confined within psoriatic plaques; include any applicable GPPPGA scores, BSA, or systemic signs used to support the diagnosis and treatment need.

• Document presence of primary, sterile, macroscopically visible pustules on erythematous skin.
• Document that pustulation is not restricted to the acral region or within psoriatic plaques.
• Include objective measures when available (GPPPGA total and pustulation subscores, %BSA with erythema and pustules) and relevant systemic signs (fever, elevated CRP, leukocytosis with neutrophilia) as applicable.

Document FDA diagnosis, age and weight for coverage decisions

For coverage, document the FDA‑indicated diagnosis (GPP) and confirm age and weight eligibility for pediatric patients (≥12 years and ≥40 kg); ensure documentation aligns with benefit plan and state/contractual requirements.

• Include patient age and weight in the request (pediatric patients must be ≥12 years and ≥40 kg).
• For SC maintenance, include prescriber attestation of clinical benefit for continuation and, if applicable, explanation why patient/caregiver cannot administer injections.

Avoid excess IV dosing (>2 doses per single flare)

Do not administer more than two IV doses of Spevigo for a single GPP flare; IV administration beyond two doses per flare is considered unproven and not medically necessary and may result in denial.

• If a patient previously treated for a prior flare has a new separate flare, that new flare may be treated with up to two IV doses.
• Requests for >2 IV doses in a single flare should be expected to be denied as not medically necessary.

Ensure requests comply with federal, state (OAC), and contractual benefit rules

Apply the applicable governing benefit rules when submitting requests: reference federal, state (Ohio Administrative Code), or contractual coverage requirements, as these govern in the event of conflict with this policy.

• Before using this policy, verify any differing federal, state (OAC), or contractual plan terms that may control coverage.
• Coverage determinations must align with those governing documents; conflicts are resolved in favor of federal/state/contractual requirements.