CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Skyrizi (risankizumab-rzaa) coverage for Psoriasis, Psoriatic Arthritis, and Crohn's Disease

Defines prior authorization, clinical criteria for initial and continuation coverage, required documentation, prescriber specialties, dosing limits adherence, TB screening, contraindications with concomitant biologics/targeted synthetics, and examples of clinical reasons to avoid conventional systemic agents for risankizumab (Skyrizi) in adults with plaque psoriasis, psoriatic arthritis, or Crohn's disease.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySkyrizi (risankizumab-rzaa) coverage for Psoriasis, Psoriatic Arthritis, and Crohn's Disease

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit chart notes or medical record documentation/claims history supporting diagnosis, affected areas and BSA, previous medications tried and responses or clinical reasons to avoid prior therapies for initial requests; for continuation, submit documentation of decreased BSA or clinical improvement/remission.

POLICY UPDATE CHANGES

No material clinical/coverage changes

3Covered Indications

12Authorization Duration (months)

>=3%/>=10%Psoriasis BSA thresholds

Coverage Summary

Coverage stance: covered_with_criteria for adults with plaque psoriasis, psoriatic arthritis, and Crohn's disease when the clinical criteria are met and no exclusions apply. Approvals align with FDA‑approved indications and compendial uses and are subject to indication‑specific requirements and dosing limits consistent with labeling and evidence‑based guidance.

Prescriber specialty and safety requirements: medication must be prescribed by or in consultation with the listed specialist for the indication (dermatologist for plaque psoriasis; rheumatologist or dermatologist for psoriatic arthritis; gastroenterologist for Crohn’s disease). A documented negative TB test (PPD, IGRA, or chest X‑ray) within 6 months is required for biologic/targeted synthetic‑naive persons; positive screens require confirmatory testing and treatment of latent TB prior to initiation. Concomitant use with any other biologic drug or targeted synthetic drug is not permitted.

Quick Facts / Thresholds

Covered Indications3

Authorization Duration12 months

Psoriasis BSA thresholds>= 10% OR >= 3% plus prior therapy failure or contraindication

TB screening recencyNegative TB test within 6 months prior to initiating therapy for biologic/ts-naive members

Concomitant therapy restrictionCannot be used with other biologic or targeted synthetic drugs

General Safety & Concomitant Therapy Criteria

Positive clinical response: evidence of low disease activity or improvement in signs and symptoms compared with baseline as specified by indication — for plaque psoriasis, reduction in body surface area (BSA) affected or maintenance of low disease activity; for psoriatic arthritis, improvement in measures such as number of swollen or tender joints, dactylitis, enthesitis, axial disease, or skin/nail involvement; for Crohn’s disease, remission or improvement in symptoms (diarrhea, abdominal pain), weight, hematocrit, CDAI score, or mucosal appearance on endoscopy/CTE/MRE/intestinal ultrasound.

Provider Actions & Prior Authorization Requirements

Prior Authorization

Submit documentation for prior authorization

Submit chart notes or medical record documentation and/or claims history supporting the diagnosis, affected areas and body surface area (BSA), prior medications tried and responses or clinical reasons to avoid prior therapies for initial requests. For continuation requests, submit documentation showing decreased BSA or other clinical improvement/remission.

Documentation Required

TB screening requirement

Provide documentation of a negative TB test (tuberculosis skin test [PPD], an interferon-gamma release assay [IGRA], or a chest X-ray) within 6 months of initiating therapy for persons naive to biologic or targeted synthetic drugs. If screening is positive, provide further testing to confirm no active disease; do not administer the medication to members with active TB. If latent TB is identified, documentation that TB treatment was started prior to initiation is required.

Documentation Required

Prescriber specialty requirement

Medication must be prescribed by or in consultation with the following specialists: dermatologist for plaque psoriasis; rheumatologist or dermatologist for psoriatic arthritis; gastroenterologist for Crohn's disease (documentation of consultation is acceptable).

Billing Rule

Authorization duration

Approvals are issued for 12 months for both initial and continuation authorizations when the applicable criteria are met.

Denial Risk

Concomitant biologic/targeted synthetic use

Claims may be denied if the member is using the requested medication concomitantly with any other biologic drug or targeted synthetic drug.

Background

Skyrizi (risankizumab‑rzaa) indication summary: indicated for adults for treatment of moderate‑to‑severe plaque psoriasis, active psoriatic arthritis, and moderately to severely active Crohn’s disease. Coverage is aligned to FDA‑approved indications and compendial uses, with approval contingent on meeting the policy’s clinical criteria.

Prescriber specialty, TB screening, and concomitant therapy: the medication must be prescribed by or in consultation with the appropriate specialist (dermatologist for plaque psoriasis; rheumatologist or dermatologist for psoriatic arthritis; gastroenterologist for Crohn’s disease). Documented negative TB testing within 6 months is required for biologic/targeted synthetic‑naive persons; positive TB screens require confirmatory testing and treatment of latent TB prior to initiation. The agent must not be used concomitantly with any other biologic or targeted synthetic therapy. Approvals may be subject to dosing limits per FDA labeling and accepted compendia.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySkyrizi (risankizumab-rzaa) coverage for Psoriasis, Psoriatic Arthritis, and Crohn's Disease

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

On This Page

OpenPayer

Skyrizi (risankizumab-rzaa) coverage for Psoriasis, Psoriatic Arthritis, and Crohn's Disease

Coverage Summary

Initial Therapy Criteria (by indication)

Continuation / Maintenance Criteria

General Safety & Concomitant Therapy Criteria

Provider Actions & Prior Authorization Requirements

Applicable Codes

Clinical Evidence & References

Background