Neighborhood Health Plan RI Skyrizi Coverage Update

Coverage Criteria for Skyrizi (risankizumab-rzaa)

Initial Therapy

Coverage is provided when ALL of the following general requirements are met and additional indication-specific criteria are satisfied:

General eligibility: Patient is at least 18 years of age; physician has assessed baseline disease severity using an objective measure/tool; patient is up to date with age-appropriate vaccinations prior to initiating therapy; patient has been evaluated and screened for latent tuberculosis prior to treatment and will receive ongoing TB monitoring during treatment; patient does not have an active infection; patient will not receive live vaccines during therapy; patient is not on concomitant injectable biologic response modifiers (including TNF-inhibitors or IL-inhibitors) or specified oral non-biologic agents; MMP members with prior receipt within the past 365 days are not subject to step therapy requirements.

Supports all indications

Moderate to severe plaque psoriasis (PsO): Prescribed by or in consultation with a specialist in dermatology or rheumatology; at least 10% body surface area affected OR crucial body areas involved (hands, feet, face, neck, scalp, genitals/groin, intertriginous areas); documented inadequate response or intolerance to at least a 3-month trial of methotrexate, cyclosporine, or acitretin OR at least a 3-month trial of phototherapy unless intolerant; documentation of inadequate response or intolerance to Zoryve (roflumilast) cream within the last 12 months unless BSA ≥20% (in which case Zoryve trial not required); documented inadequate response/intolerance/contraindication to at least a 3-month trial of adalimumab AND at least a 6-month trial of an ustekinumab biosimilar at maximum tolerated doses.

Also requires prior biologic trials

Active psoriatic arthritis (PsA): Prescribed by or in consultation with a specialist in dermatology or rheumatology; documented moderate to severe active disease; if predominantly axial disease or active enthesitis/dactylitis, inadequate response or intolerance to at least two NSAIDs unless contraindicated; if peripheral arthritis, inadequate response to at least a 3-month trial of one oral DMARD (e.g., methotrexate, azathioprine, sulfasalazine, hydroxychloroquine) unless intolerant; documented inadequate response/intolerance/contraindication to at least a 3-month trial of adalimumab AND at least a 6-month trial of an ustekinumab biosimilar at maximum tolerated doses.

PsA prior therapy requirements

Moderately to severely active Crohn's disease (CD): Prescribed by or in consultation with a specialist in gastroenterology; documented moderate to severe active disease; inadequate response, intolerance, or contraindication to at least a 3-month trial of infliximab IV or adalimumab at maximum tolerated doses; inadequate response, intolerance, or contraindication to at least a 6-month trial of an ustekinumab biosimilar at maximum tolerated doses.

Also specifies IV induction dosing regimen in dosing section

Moderately to severely active ulcerative colitis (UC): Prescribed by or in consultation with a specialist in gastroenterology; documented moderate to severe disease; inadequate response, intolerance, or contraindication to at least a 3-month trial of infliximab IV or adalimumab at maximum tolerated doses; inadequate response, intolerance, or contraindication to at least a 6-month trial of an ustekinumab biosimilar at maximum tolerated doses.

Also specifies IV induction dosing regimen in dosing section

Continuation Therapy

Coverage for continuation varies by formulation and indication:

Skyrizi IV (induction): Induction doses given as the IV formulation cannot be renewed; coverage for IV induction is not renewable.

No renewals for IV formulation

Skyrizi SC for plaque psoriasis: Authorization of up to 12 months may be granted when the member achieves or maintains a positive clinical response evidenced by reduction in BSA from baseline or improvement in signs and symptoms (e.g., itching, redness, flaking, scaling, burning, cracking, pain); documentation that the member previously had inadequate response, intolerance, or contraindication to at least a 6-month trial of an ustekinumab biosimilar at maximum tolerated dose is required.

Continuation requires documented response

Skyrizi SC for psoriatic arthritis: Authorization of up to 12 months may be granted when the member achieves or maintains a positive clinical response evidenced by improvement from baseline in number of swollen and/or tender joints, dactylitis, enthesitis, or skin/nail involvement; documentation of prior inadequate response, intolerance, or contraindication to at least a 6-month trial of an ustekinumab biosimilar at maximum tolerated dose is required.

Coverage linked to diagnosis and HCPCS

Covered when ALL of the following are met

Required codes: The claim includes HCPCS J2327 (injection, risankizumab-rzaa, intravenous, 1mg) and one of the covered ICD-10 diagnosis codes listed in Appendix 1 (Crohn's disease or ulcerative colitis variants).

Based on HCPCS and Appendix 1 diagnosis listing

Skyrizi IV administered as the induction regimen is a non‑renewable benefit. IV induction dosing cannot be renewed; requests to continue or reauthorize the IV induction series should be denied and transitioned to the appropriate maintenance formulation (typically subcutaneous) per policy guidance.

Coverage for risankizumab is limited to the specific ICD‑10 diagnosis codes listed in Appendix 1. Any diagnosis not listed in Appendix 1 is not included in the covered diagnosis set for this policy excerpt and may result in claim denial if submitted.

Requests that exceed the stated quantity limits are subject to denial or additional review. For example, the policy sets a quantity limit of 150 mg per 12 weeks for plaque psoriasis and psoriatic arthritis (with specific loading‑dose allowances) and defines maintenance limits for inflammatory bowel disease (e.g., Crohn’s and ulcerative colitis maintenance dosing expressed as 360 mg per 8 weeks or 180–360 mg per 8 weeks). Requests above these limits should follow the policy’s quantity‑limit workflow and may be denied if not justified.

Billing and Code Listings

HCPCS CodesHCPCS

J2327

injection, risankizumab-rzaa, intravenous, 1mg

NDC(s)NDC

00074-5015-xx	Skyrizi carton containing one 600 mg/10 mL single-dose vial
0074-2100-xx	Skyrizi 150mg/ml single dose pen
0074-1050-xx	Skyrizi 150mg/ml single dose prefilled syringe

HCPCSHCPCSCovered

J2327

injection, risankizumab-rzaa, intravenous, 1mg

NDCNDC

00074-5015-xx	Skyrizi carton containing one 600 mg/10 mL single-dose vial
0074-2100-xx	Skyrizi 150mg/ml single dose pen
0074-1050-xx	Skyrizi 150mg/ml single dose prefilled syringe

Covered ICD-10 Diagnosis CodesICD-10Covered

K50.00	Crohn's disease of small intestine without complications
K50.011	Crohn's disease of small intestine with rectal bleeding
K50.012	Crohn's disease of small intestine with intestinal obstruction
K50.013	Crohn's disease of small intestine with fistula
K50.014	Crohn's disease of small intestine with abscess
K50.018	Crohn's disease of small intestine with other complication
K50.019	Crohn's disease of small intestine with unspecified complications
K50.10	Crohn's disease of large intestine without complications
K50.111	Crohn's disease of large intestine with rectal bleeding
K50.112	Crohn's disease of large intestine with intestinal obstruction

1–10 of 63

1/7

Max units/induction dosing

Ulcerative colitis induction (IV)1200 mg administered IV at Weeks 0, 4, and 8 (three induction doses)

NDC quantity for IV vialSkyrizi 600 mg/10 mL single‑dose vial — carton quantity limit: 3 for Weeks 0, 4 & 8

N/A

Coding noteN/A

HCPCS presentJ2327 is the HCPCS code listed for risankizumab (intravenous, 1 mg)

NDCs enumerated elsewhere

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior authorization for J2327

Prior authorization is required for risankizumab when submitted with HCPCS J2327. Requests must include a covered ICD-10 diagnosis from Appendix 1. Providers may include the NDC when relevant to billing.

Prior authorization required for HCPCS J2327
Submit one covered ICD-10 diagnosis from Appendix 1
Include NDC on request/claim when applicable

Denial Risk

IV induction non-renewable

Induction dosing with Skyrizi IV is not renewable. Authorization for IV induction doses will be denied for renewal requests; only initial induction coverage is allowed.

Do not request renewal for Skyrizi IV (induction)
Renewals may be considered only for appropriate SC maintenance formulations per policy

Background

Risankizumab‑rzaa (Skyrizi) is an interleukin‑23 (IL‑23) inhibitor indicated for plaque psoriasis, psoriatic arthritis, and inflammatory bowel disease including Crohn’s disease and ulcerative colitis. For IBD, the product is initiated with an intravenous induction series followed by subcutaneous maintenance; specialty prescribing or consultation and objective measures of baseline disease are required by the policy.

Definitions and Presentations

Moderate to severe plaque psoriasis

BSA thresholdAt least 10% of body surface area affected

Crucial body areas involvementInvolvement of hands, feet, face, neck, scalp, genitals/groin, or intertriginous areas qualifies

Definition summaryModerate to severe plaque psoriasis defined by ≥10% BSA OR involvement of crucial body areas

Skyrizi presentations / NDCs

600 mg vial presentationSkyrizi carton containing one 600 mg/10 mL single‑dose vial — NDC 00074-5015-xx

150 mg/mL single‑dose penSkyrizi 150 mg/mL single‑dose pen — NDC 0074-2100-xx

OpenPayer

Skyrizi (risankizumab‑rzaa) — IV and SC coverage criteria

Coverage Criteria for Skyrizi (risankizumab-rzaa)

Billing and Code Listings

Prior Authorization, Documentation, and Provider Requirements

Background

Definitions and Presentations