Policy Application
All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the
www.fepblue.org
website.
Spesolimab (Spevigo) may be considered medically necessary when
ALL
of the following criteria are met:
-
The individual has a diagnosis of generalized pustular psoriasis (GPP);
and
-
The individual is experiencing a moderate to severe flare of GPP;
and
-
If the individual has an FDA labeled indication, then ONE of the following:
-
The individual'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 individual's age;
and
-
The prescriber is a specialist in the area of the individual's diagnosis (e.g., dermatologist) or the prescriber has consulted with a specialist in the area of the individual's diagnosis;
and
- The individual has not received two (2) or more infusions for the current flare.
Length of approval:
One (1) month for up to two 900mg doses
The use of spesolimab (Spevigo)
for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
