Spesolimab-sbzo (Spevigo) — CPB 1013 | AETNA Coverage Update

Aetna modified CPB 1013 for spesolimab-sbzo (Spevigo), effective September 26, 2025. Here's what billing teams need to know before submitting claims.

Aetna, a CVS Health company, updated Clinical Policy Bulletin 1013 covering spesolimab-sbzo (Spevigo) — the IL-36 receptor antagonist used for generalized pustular psoriasis (GPP). The key billing code for this drug is HCPCS J1747 (injection, spesolimab-sbzo, 1 mg), and precertification is required for all participating providers and members in applicable plan designs. This update affects dermatology and infusion billing teams who bill Aetna commercial plans for Spevigo administration.

Quick-Reference Table

Aetna Spesolimab-sbzo Coverage Criteria and Medical Necessity Requirements 2025

The Aetna spesolimab-sbzo coverage policy under CPB 1013 applies to commercial medical plans only. If you're billing Medicare, stop here — Aetna's Medicare criteria are separate and published at their Medicare Part B step therapy page.

Precertification is mandatory. Every Aetna participating provider and member in an applicable plan design must get prior authorization before Spevigo is administered. There are no exceptions for urgent infusions or new starts — if the cert isn't in place, the claim is at risk.

To get precertification, call (866) 752-7021 or fax (888) 267-3277. For Statement of Medical Necessity forms, go to Aetna's Specialty Pharmacy Precertification page.

The primary covered diagnosis under this coverage policy is L40.1 — generalized pustular psoriasis. The code table also references atopic dermatitis codes (L20.0–L20.9) and ulcerative colitis codes (K51.011–K51.919), which signals Aetna is tracking spesolimab research across multiple IL-36-driven conditions. Whether Aetna will cover Spevigo for those indications today is a separate question, and the policy doesn't say yes. Treat those ICD-10 codes as watch codes — not covered indications — until Aetna explicitly says otherwise.

The billing code for the drug itself is J1747, billed per 1 mg of spesolimab-sbzo. Administration is billed separately using the appropriate infusion CPT codes from the 96365–96417 range, depending on route and time. The policy also flags CPT 86480, 86481, and 86580 as related codes — tuberculosis testing is a standard pre-biologic safety screen, and Aetna wants to see that documentation in the record.

Medical necessity documentation should include the confirmed GPP diagnosis, prior treatment history, and TB screening results. Your precert submission is the first place Aetna's reviewers will look, so don't let the documentation be thin.

Coverage Indications at a Glance

Aetna Spesolimab-sbzo Billing Guidelines and Action Items 2025

The real issue here is the precertification requirement. A missed cert on a drug that costs this much will hurt. Get your workflow right before September 26, 2025.

If you're managing a high volume of Spevigo patients across both commercial and Medicare Aetna plans, talk to your compliance officer before the effective date. The dual-policy structure creates real audit exposure if the wrong criteria are applied to the wrong member population.

CPT, HCPCS, and ICD-10 Codes for Spesolimab-sbzo Under CPB 1013

Covered HCPCS Code (When Selection Criteria Are Met)

Other HCPCS Codes Related to CPB 1013

These codes appear in the policy as comparators, prior-line therapies, or related agents. They are not covered codes for spesolimab itself — they're context codes that inform the prior authorization review and step therapy documentation.

CPT Codes Related to CPB 1013

Key ICD-10-CM Diagnosis Codes