CurrentViva HealthPolicy N/A

Spevigo (spesolimab) — Intravenous for Generalized Pustular Psoriasis (GPP)

Medical necessity policy governing coverage of intravenous Spevigo (spesolimab) for treatment of generalized pustular psoriasis flares for Viva Health members; specifies approval criteria, dosing, and billing codes.

Policy Summary

PayerViva Health

PolicySpevigo (spesolimab) — Intravenous for GPP

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateMar 4, 2025

Key ActionObtain prior authorization with documentation meeting the Initial Approval Criteria and bill drug with HCPCS J1747 (1 mg = 1 billable unit).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 monthlength of authorization

900initial IV dose (mg)

300maintenance dose (mg)

not renewablerenewal policy

L40.1covered diagnosis

Coverage Criteria for Spevigo (spesolimab)

Initial Approval — Covered when ALL of the following are met:

Covered when ALL of the following are met:

Initial Approval Criteria: The patient has a diagnosis of generalized pustular psoriasis (GPP);

Moderate to severe flare

ONE of: The patient has a Generalized Pustular Psoriasis Physician Global Assessment (GPPPGA) total score of 3 or greater;
OR: The patient has a GPPPGA pustulation subscore of 2 or greater;
OR:

Policy Summary

PayerViva Health

PolicySpevigo (spesolimab) — Intravenous for GPP

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateMar 4, 2025

Key ActionObtain prior authorization with documentation meeting the Initial Approval Criteria and bill drug with HCPCS J1747 (1 mg = 1 billable unit).

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.

The patient has erythema and pustules covering 5% or greater of body-surface area (BSA);

OR: The patient has new appearance or worsening of pustules;

Age or evidence for use

ONE of: The patient's age is within FDA labeling for the requested indication for the requested agent;
OR: There is support for using the requested agent for the patient's age;

Prescriber requirement: The prescriber is a specialist in the area of the patient's diagnosis (e.g., dermatologist) or the prescriber has consulted with a specialist in the area of the patient's diagnosis;

TB screening/management

ONE of: The patient does NOT have active or latent tuberculosis (TB);
OR: The patient has latent tuberculosis (TB) and has begun or completed therapy for latent TB prior to initiating the requested agent;

Combination therapy prohibition: The patient will NOT be using the requested agent in combination with another immunomodulatory agent (e.g., TNF inhibitors, JAK inhibitors, IL-4 inhibitors, PDE4 inhibitors) for the requested indication;

Contraindications: The patient does NOT have any FDA labeled contraindications to the requested agent;

Dose within labeling: The requested quantity (dose) is within FDA labeled dosing for the requested indication;

Prior infusions: The patient has not received 2 or more infusions for the current flare;

The patient must not receive the requested agent in combination with another immunomodulatory agent for the same indication. Examples of prohibited combination agents include, but are not limited to, TNF inhibitors, JAK inhibitors, IL-4 inhibitors, and phosphodiesterase‑4 (PDE4) inhibitors. This restriction is a condition of initial approval and must be met in the documentation submitted for prior authorization.

Coverage is limited to a single authorization for the current GPP flare; renewal requests are not allowed and continued therapy beyond the initial authorization is not covered. Providers should plan treatment and billing accordingly and include all necessary documentation with the initial prior authorization to support the one‑time approval.

Coding and Diagnostic Criteria

HCPCS CodesHCPCS

J1747

Injection, spesolimab-sbzo, 1 mg; 1 billable unit = 1 mg

NDCsNDC

00597-0035xx

Spevigo 450 mg/7.5 mL two-pack single-dose vial for intravenous use

Covered ICD-10 Diagnosis CodesICD-10Covered

L40.1

Generalized pustular psoriasis

inv-07: GPPPGA total score — threshold value.

GPPPGA total score thresholdGPPPGA total score ≥ 3

inv-08: GPPPGA pustulation subscore — threshold value.

GPPPGA pustulation subscore thresholdGPPPGA pustulation subscore ≥ 2

inv-09: Body surface area involvement — threshold value (>=5% BSA).

Body surface area involvement thresholdErythema and pustules covering ≥ 5% of body-surface area (BSA)

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Billing

Prior authorization is required for Spevigo (spesolimab-sbzo). Billing must use HCPCS code J1747 - Injection, spesolimab-sbzo, 1 mg (1 billable unit = 1 mg). Follow applicable CMS modifier guidance (e.g., JA for intravenous infusion, JB for subcutaneous) as appropriate.

Prior authorization required
HCPCS: J1747

Documentation Required

Required Documentation to Support Prior Authorization

Documentation submitted with the prior authorization request must demonstrate the diagnosis of generalized pustular psoriasis (GPP) and evidence of a moderate to severe GPP flare. Acceptable documentation includes GPPPGA total score or pustulation subscore, body-surface area (BSA) involvement, and clinical description of new or worsening pustules. Include prescriber specialty/consultation, TB status and management (if applicable), FDA-label age support or rationale for use by age, confirmation that the requested dose is within FDA labeling, and that combination therapy with other immunomodulatory agents will not be used.

Diagnosis: generalized pustular psoriasis (GPP)
Severity: one of — GPPPGA total score ≥ 3; GPPPGA pustulation subscore ≥ 2; erythema and pustules ≥ 5% BSA; new or worsening pustules
Prescriber: dermatologist or specialist, or documentation of specialist consultation
TB: no active TB OR latent TB with documentation of initiation/completion of latent TB therapy prior to starting therapy
Age: within FDA labeling for the agent or supportive rationale for use outside labeled ages
Dose: requested quantity within FDA-labeled dosing
Combination therapy: documentation that the agent will not be combined with other immunomodulatory agents
Treatment history: documentation that patient has not received ≥ 2 infusions for the current flare

Background and Clinical Context

Generalized pustular psoriasis (GPP) is a severe dermatologic condition characterized by widespread sterile pustules and can present with systemic symptoms. In this policy the treated episode is a moderate to severe flare, defined by any ONE of the following: a GPPPGA total score ≥ 3; a GPPPGA pustulation subscore ≥ 2; erythema and pustules covering ≥ 5% body surface area (BSA); or the new appearance or worsening of pustules. The policy requires a confirmed diagnosis of GPP and documentation of flare severity to meet the initial approval criteria.

Definitions and Flare Severity

inv-15: Moderate to severe flare of GPP — Defined by ONE of several listed thresholds (GPPPGA, pustulation subscore, BSA, new/worsening systemic features).

Definition of moderate to severe GPP flarePresence of ONE of: GPPPGA total score ≥ 3; GPPPGA pustulation subscore ≥ 2; erythema and pustules covering ≥ 5% BSA; OR new appearance or worsening of pustules.