Spevigo (spesolimab-sbzo) — United Healthcare

generalized pustular psoriasis (GPP)

Initial criteria

Diagnosis of generalized pustular psoriasis (GPP) based on both of the following: (1) Presence of primary, sterile, macroscopically visible pustules on erythematous base AND (2) Pustulation is not restricted to the acral region or within psoriatic plaques
Used to prevent GPP flares
Patient is not currently experiencing a GPP flare
One of the following: (1) Patient has been established on therapy with Spevigo for GPP under an active UnitedHealthcare medical benefit prior authorization OR (2) Both of the following: (a) Patient is currently on Spevigo therapy for GPP as documented by claims history or medical records (Document date and duration of therapy) AND (b) Patient has not received a manufacturer supplied sample at no cost in the prescriber’s office, or via manufacturer’s patient assistance programs as a means to establish as a current user of Spevigo
Patient is not receiving Spevigo in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), ustekinumab, Skyrizi (risankizumab)] for treatment of the same indication
Prescribed by a dermatologist

Documentation of positive clinical response to therapy [e.g., preventing flares, reducing frequency of flares, prolonging time between flares, controlling signs and symptoms of GPP (e.g., pustules, erythema, pain, itching) between flares]
Reduction in the utilization of therapy (e.g., intravenous Spevigo) used for GPP flares
Patient is not receiving Spevigo in combination with another targeted immunomodulator [e.g., Enbrel (etanercept), Cimzia (certolizumab), Simponi (golimumab), Orencia (abatacept), adalimumab, Xeljanz (tofacitinib), Olumiant (baricitinib), Rinvoq (upadacitinib), ustekinumab, Skyrizi (risankizumab)] for treatment of the same indication
Prescribed by a dermatologist

12 months