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
- The individual is 18 years of age or older; 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.
Procedure Codes
