J1747, Injection, spesolimab-sbzo, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Claims require prescription by a dermatologist and authorization limited to 21 days.
Key Coverage Criteria
- Covered when hospital outpatient facility infusion services for specialty medications and IVIG/SCIG therapy are considered medically necessary and the member meets the specific clinical criteria described in the policy.
- Intravenous Spevigo is covered for a GPP flare when (1) there is a diagnosis of GPP, (2) a GPP flare is present, (3) Spevigo dosing follows FDA-labeled dosing for GPP flares, (4) total dose does not exceed two doses per single GPP flare (with up to two doses allowed if a previous GPP flare has occurred), and (5) authorization is for no more than 21 days.
- Medically necessary for generalized pustular psoriasis (GPP) if (a) patient is >=12 years old and weighs >=40 kg, and (b) current flare is or has previously been of moderate to severe intensity.
- Spesolimab-sbzo (Spevigo®) is medically necessary for treatment of generalized pustular psoriasis (GPP) when the patient is 12 years or older, weighs at least 40 kg, and has an existing or previous moderate-to-severe flare.
- Spesolimab-sbzo (Spevigo) is medically necessary for treating generalized pustular psoriasis (GPP) in patients who are aged 12 years or older (weighing at least 40 kg) and have an existing or prior flare of moderate-to-severe intensity.
- Spesolimab-sbzo (Spevigo®) is medically necessary for the treatment of generalized pustular psoriasis (GPP) when: (a) patient is 12 years or older and weighs at least 40 kg, and (b) has an existing or prior flare that was moderate to severe in intensity.
10 Active Policies
UHC-POL-provider-administered-drugs-soc, Provider Administered Drugs – Site of Care
UHC-POL-spevigo, Spevigo (Spesolimab-Sbzo)
UHC-POL-spevigo-sv, Spevigo (Spesolimab-Sbzo) – IV and Subcutaneous Formulations (for UHCWest Only)
BCBSIL-RX501.181, Spesolimab-sbzo
BCBSMT-RX501.181, Spesolimab-sbzo
Related Codes
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