Spesolimab-sbzo (Spevigo) (CPB 1013, reviewed 2026-04-02)

REQUIREMENTS: Before April 2, 2026: (1) Billing team must establish precertification workflow for J1747 (spesolimab-sbzo) with precertification phone line (866) 752-7021 or fax (888) 267-3277. (2) Update billing system to flag claims for J1747 requiring prior authorization; block claims without precertification approval. (3) Create documentation checklist for providers requiring: confirmation of dermatologist involvement, confirmation of GPP diagnosis with one of four required criteria (gene variant documentation, skin biopsy with Kogoj's spongiform pustules, systemic symptoms/lab abnormalities with reference ranges, or GPPPGA score ≥3 with ≥5% BSA involvement). (4) For maintenance therapy (non-flare GPP), require documentation of documented GPP history (relapsing >1 episode or persistent >3 months) plus history of ≥2 moderate-to-severe flares OR flaring while on concomitant therapy (retinoids, methotrexate, cyclosporine), with current clear-to-almost-clear skin status. (5) Implement mandatory TB screening documentation requirement (TST or IGRA within 12 months prior to initiation) in precertification forms; block approval if TB screening missing or positive without confirmation testing/treatment plan. (6) Add system rule: deny claims if member is concurrently receiving other biologic or targeted synthetic drugs for same indication. (7) Ensure site of care utilization management policy is applied per separate policy. (8) Providers must verify member age ≥12 years and weight ≥40 kg before billing. (9) Verify correct route (IV for acute flare at 900 mg over 90 minutes; SC for maintenance at 600 mg loading then 300 mg every 4 weeks). Failure to obtain precertification will result in claim denials.