CurrentMass General Brigham Health PlanPolicy N/A

Skyrizi (risankizumab-rzaa) coverage

Defines prior authorization, specialty pharmacy, quantity limits, indications, and medical necessity criteria for Skyrizi for Commercial/Exchange members under Mass General Brigham Health Plan.

Policy Summary

PayerMass General Brigham Health Plan

PolicySkyrizi (risankizumab-rzaa) coverage

Policy CodePolicy N/A

Change TypeMinor update / no material change

Effective DateMay 1, 2026

Next Review DateMay 14, 2025

Key ActionObtain prior authorization and submit medical records demonstrating current treatment or improvement when requesting initiation or reauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial/ExchangePlan applicability

24 monthsSC initial and reauthorization approval length

3 infusionsInitial IV approval

>=3% BSAPlaque psoriasis BSA threshold

Coverage Criteria

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Plaque psoriasis criteria: 1. Diagnosis of moderate to severe plaque psoriasis.

Plaque psoriasis criteria: 2. At least 3% of body surface area (BSA) is affected OR crucial body areas (e.g., hands, feet, face, neck, scalp, genitals/groin, intertriginous areas) are affected.

Plaque psoriasis criteria

ONE of: a. Minimum duration of 4-week trial and failure, contraindication, or intolerance to ONE topical therapy: corticosteroids (e.g., betamethasone, clobetasol); vitamin D analogs (e.g., calcitriol, calcipotriene); tazarotene; calcineurin inhibitors (e.g., tacrolimus, pimecrolimus); anthralin; coal tar.
ONE of: b. Member has severe psoriasis that warrants a biologic DMARD as first-line therapy.

Psoriatic arthritis (Initial therapy)

Covered when ALL of the following are met:

Psoriatic arthritis criteria: 1. Diagnosis of active psoriatic arthritis.

Psoriatic arthritis criteria

ONE of: a. Actively inflamed joints.
ONE of: b. Dactylitis.
ONE of: c. Enthesitis.
ONE of: d. Axial disease.
ONE of: e. Active skin and/or nail involvement.

Crohn's disease (Initial therapy)

Covered when ALL of the following are met:

Crohn's disease criteria: 1. Diagnosis of moderately to severely active Crohn's disease.

Crohn's disease criteria

ONE of: a. Member has had trial and failure, intolerance, or contraindication to ONE conventional therapy: 6-mercaptopurine; azathioprine; corticosteroids (e.g., prednisone); methotrexate.
ONE of: b. Disease severity warrants systemic biologic as first-line therapy.

Crohn's disease criteria

ONE of: a. SC formulation will be used as maintenance therapy following IV induction.
ONE of: b. Member has received the IV induction doses and is transitioning to maintenance therapy.

Ulcerative colitis (Initial therapy)

Covered when ALL of the following are met:

Ulcerative colitis criteria: 1. Diagnosis of moderately to severely active ulcerative colitis.

Ulcerative colitis criteria

ONE of: a. Member has had a trial and failure, intolerance, or contraindication to ONE conventional therapy: 6-mercaptopurine; aminosalicylate (e.g., mesalamine, olsalazine, sulfasalazine); azathioprine; corticosteroids (e.g., prednisone).
ONE of: b. Disease severity warrants systemic biologic as first-line therapy.

Ulcerative colitis criteria

ONE of: a. SC formulation will be used as maintenance therapy following IV induction.
ONE of: b. Member has received the IV induction doses and is transitioning to maintenance therapy.

Continuation of therapy (all indications)

Covered when ALL of the following are met:

Reauthorization criteria: 1. Submission of medical records (e.g., chart notes) demonstrating an improvement in the member's condition, as evidenced by low disease activity or improvement in signs and symptoms of the condition.

Reauthorization criteria: Authorization length: Initial and reauthorization approvals are limited to 24 months for SC formulations; initial IV induction limited to 3 infusions over 12 weeks.

Coding and Limits

Quantity limits by formulationNDC

Skyrizi SC 150 mg	150 mg prefilled syringe/autoinjector — Psoriatic Arthritis/Plaque Psoriasis: 1 injection every 12 weeks
Skyrizi IV 600 mg/10 mL	IV infusion — Crohn's Disease: 600 mg at weeks 0, 4, and 8; Ulcerative Colitis: 1,200 mg at weeks 0, 4, and 8
Skyrizi SC 180 mg/1.2 mL cartridge	SC cartridge — Ulcerative Colitis and Crohn's Disease: 1 injection every 8 weeks
Skyrizi SC 360 mg/2.4 mL cartridge	SC cartridge — Ulcerative Colitis and Crohn's Disease: 1 injection every 8 weeks

Body surface area (BSA) — plaque psoriasis threshold

BSA threshold for plaque psoriasis>= 3% of body surface area (BSA) affected

Alternate criterionCrucial body areas affected (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas)

Context within criteriaRequired in combination with diagnosis of moderate-to-severe plaque psoriasis and trial of topical therapy or severe disease warranting biologic

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Specialty Pharmacy

Prior authorization required for Skyrizi under the pharmacy benefit for Commercial/Exchange members. This medication is designated specialty and must be dispensed by a contracted specialty pharmacy.

Plan: Commercial/Exchange
Benefit: Pharmacy Benefit
Specialty dispensing required: contracted specialty pharmacy

Documentation Required

Documentation for New-to-Plan Members and Meeting Diagnosis Criteria

For members new to the plan (coverage effective date ≤ 90 days), submit medical records documenting that the member is currently receiving the requested drug (records from samples or manufacturer patient assistance programs are excluded). Authorization may be granted when documentation demonstrates current treatment with the requested drug OR when all diagnosis‑specific criteria in the policy are met.

New-to-plan evidence: coverage effective date ≤ 90 days
Required documentation: medical records showing current receipt of the requested drug (excluding samples or manufacturer assistance)

Step Therapy

Therapy Trial Requirements

Trials of specified conventional or topical therapies are required for each indication unless disease severity warrants biologic therapy as first‑line. For plaque psoriasis, require a ≥4‑week trial and failure/intolerance/contraindication to ONE topical therapy from the listed classes (or biologic first‑line if severe). For Crohn's disease and ulcerative colitis, require trial and failure/intolerance/contraindication to ONE conventional systemic therapy listed (or biologic first‑line if severity warrants). For SC maintenance use, member must either follow IV induction or have received IV induction doses prior to transitioning to SC maintenance as specified.

Plaque psoriasis: ≥4‑week trial and failure/intolerance/contraindication to ONE topical therapy (corticosteroids, vitamin D analogs, tazarotene, calcineurin inhibitors, anthralin, coal tar) unless severe psoriasis warrants biologic first‑line
Crohn's disease: trial and failure/intolerance/contraindication to ONE conventional therapy (6‑mercaptopurine, azathioprine, corticosteroids, methotrexate) unless severity warrants biologic first‑line; SC maintenance only after IV induction or when transitioning from IV
Ulcerative colitis: trial and failure/intolerance/contraindication to ONE conventional therapy (6‑mercaptopurine, aminosalicylates, azathioprine, corticosteroids) unless severity warrants biologic first‑line; SC maintenance only after IV induction or when transitioning from IV

Documentation Required

Required Medical Records for Reauthorization

For continuation of therapy, submit medical records (e.g., chart notes) demonstrating improvement in the member's condition — evidence of low disease activity or improvement in signs and symptoms is required for reauthorization.

Reauthorization requirement: medical records showing clinical improvement or low disease activity

Background

Skyrizi is an interleukin-23 (IL-23) antagonist indicated for adult patients with moderate-to-severe plaque psoriasis, active psoriatic arthritis, and moderately to severely active Crohn’s disease and ulcerative colitis. For plaque psoriasis the policy uses a body-surface-area threshold of ≥ 3% BSA (or involvement of crucial body areas) when assessing eligibility for therapy.

For inflammatory bowel disease indications the policy distinguishes IV induction dosing (limited to 3 infusions over 12 weeks for initial approval) from SC maintenance dosing and requires documentation of appropriate induction or transition to maintenance as specified in the criteria.

Across indications the policy requires prior trials of specified conventional or topical therapies before authorizing biologic therapy unless disease severity justifies biologic use as first-line; reauthorization requires submission of medical records demonstrating clinical improvement or low disease activity.

Policy Summary

PayerMass General Brigham Health Plan

PolicySkyrizi (risankizumab-rzaa) coverage

Policy CodePolicy N/A

Change TypeMinor update / no material change

Effective DateMay 1, 2026

Next Review DateMay 14, 2025

Key ActionObtain prior authorization and submit medical records demonstrating current treatment or improvement when requesting initiation or reauthorization.

SourceLink

On This Page

OpenPayer

Skyrizi (risankizumab-rzaa) coverage

Coverage Criteria

Coding and Limits

Provider Actions and Requirements

Indications & Definitions

Background