Subject: Specialty Quantity Limit Spevigo 5581-H P2025a

Drug

SPEVIGO  (spesolimab-sbzo)

Policy:

Program Description

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. If the member’s plan allows a quantity limit exception review for the requested medication, coverage of an additional quantity may be provided up to the exception limit with prior authorization.

Covered Quantities

Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.

Medication	Standard Limit	Exception Limit
Spevigo (spesolimab-sbzo) 450 mg/7.5 mL single-dose vial	4 vials (2 doses) per 14 days	N/A
Spevigo (spesolimab-sbzo) 150 mg/mL prefilled syringe	2 syringes per 28 days	4 syringes per 28 days
Spevigo (spesolimab-sbzo) 300 mg/2 mL prefilled syringe	1 syringe per 28 days	2 syringes per 28 days

FDA-Recommended Dosing

Generalized pustular psoriasis flares in adults and pediatrics 12 years to 17 years of age weighing ≥ 40 kg

• 900 mg (2 vials) once. If flare symptoms persist, may administer an additional 900 mg (2 vials) one week after the initial dose.

Generalized pustular psoriasis when not experiencing a flare in adults and pediatrics 12 years to 17 years of age weighing ≥ 40 kg

• 600 mg followed by 300 mg  administered 4 weeks later and every 4 weeks thereafter. A subcutaneous loading dose is not required following treatment of a flare with intravenous Spevigo.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Spevigo [package insert]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals, Inc.; May 2025.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

July 19, 2025