UnitedHealthcare Skyrizi Prior Auth Coverage

Coverage Criteria for Skyrizi (risankizumab-rzaa)

Initial Therapy — Plaque Psoriasis

Covered when ALL of the following are met

Plaque psoriasis initial: (1) Diagnosis of moderate to severe plaque psoriasis; (2) Patient is not receiving Skyrizi in combination with another targeted immunomodulator (e.g., adalimumab, Bimzelx [bimekizumab-bkzx], Cimzia [certolizumab], Cosentyx [secukinumab], Enbrel [etanercept], Ilumya [tildrakizumab], Otezla [apremilast], Siliq [brodalumab], Sotyktu [deucravacitinib], Taltz [ixekizumab], Tremfya [guselkumab], ustekinumab).

Authorization issued for 12 months

Reauthorization — Plaque Psoriasis

Covered when ALL of the following are met

Plaque psoriasis reauth: (1) Documentation of positive clinical response to Skyrizi therapy; (2) Patient is not receiving Skyrizi in combination with another targeted immunomodulator (e.g., adalimumab, Bimzelx [bimekizumab-bkzx], Cimzia [certolizumab], Cosentyx [secukinumab], Enbrel [etanercept], Ilumya [tildrakizumab], Otezla [apremilast], Siliq [brodalumab], Sotyktu [deucravitinib], Taltz [ixekizumab], Tremfya [guselkumab], ustekinumab).

Authorization issued for 12 months

Initial Therapy — Psoriatic Arthritis

Covered when ALL of the following are met

Psoriatic arthritis initial: (1) Diagnosis of active psoriatic arthritis; (2) Patient is not receiving Skyrizi in combination with another targeted immunomodulator (e.g., adalimumab, Bimzelx [bimekizumab-bkzx], Cimzia [certolizumab], Cosentyx [secukinumab], Enbrel [etanercept], Orencia [abatacept], Otezla [apremilast], Rinvoq [upadacitinib], Simponi [golimumab], Taltz [ixekizumab], Tremfya [guselkumab], Xeljanz/Xeljanz XR [tofacitinib], ustekinumab).

Authorization will be issued for 12 months

Reauthorization — Psoriatic Arthritis

Covered when ALL of the following are met

Psoriatic arthritis reauth: (1) Documentation of positive clinical response to Skyrizi therapy; (2) Patient is not receiving Skyrizi in combination with another targeted immunomodulator (e.g., adalimumab, Bimzelx [bimekizumab-bkzx], Cimzia [certolizumab], Cosentyx [secukinumab], Enbrel [etanercept], Orencia [abatacept], Otezla [apremilast], Rinvoq [upadacitinib], Simponi [golimumab], Taltz [ixekizumab], Tremfya [guselkumab], Xeljanz/Xeljanz XR [tofacitinib], ustekinumab).

Authorization issued for 12 months

Initial Therapy — Crohn's Disease (Maintenance)

Covered when ALL of the following are met

Crohn's initial maintenance: (1) Diagnosis of moderately to severely active Crohn's disease; (2) Patient is not receiving Skyrizi in combination with another targeted immunomodulator (e.g., adalimumab, Cimzia [certolizumab], Entyvio [vedolizumab], Omvoh [mirikizumab-mrkz], Rinvoq [upadacitinib], Tremfya [guselkumab], ustekinumab).

Authorization will be issued for 12 months

Reauthorization — Crohn's Disease

Covered when ALL of the following are met

Crohn's reauth: (1) Documentation of positive clinical response to Skyrizi therapy; (2) Patient is not receiving Skyrizi in combination with another targeted immunomodulator (e.g., adalimumab, Cimzia [certolizumab], Entyvio [vedolizumab], Omvoh [mirikizumab-mrkz], Rinvoq [upadacitinib], Tremfya [guselkumab], ustekinumab).

Authorization issued for 12 months

Initial Therapy — Ulcerative Colitis

Covered when ALL of the following are met

Ulcerative colitis initial: (1) Diagnosis of moderately to severely active ulcerative colitis; (2) Patient is not receiving Skyrizi in combination with another targeted immunomodulator (e.g., adalimumab, Entyvio [vedolizumab], Omvoh [mirikizumab-mrkz], Rinvoq [upadacitinib], Simponi [golimumab], Tremfya [guselkumab], Xeljanz/Xeljanz XR [tofacitinib], ustekinumab, Zeposia [ozanimod]).

Authorization will be issued for 12 months

Reauthorization — Ulcerative Colitis

Covered when ALL of the following are met

Ulcerative colitis reauth: (1) Documentation of positive clinical response to Skyrizi therapy; (2) Patient is not receiving Skyrizi in combination with another targeted immunomodulator (e.g., adalimumab, Entyvio [vedolizumab], Omvoh [mirikizumab-mrkz], Rinvoq [upadacitinib], Simponi [golimumab], Tremfya [guselkumab], Xeljanz/Xeljanz XR [tofacitinib], ustekinumab, Zeposia [ozanimod]).

Authorization issued for 12 months

Use of Skyrizi in combination with another targeted immunomodulator is excluded from approval. Examples of targeted immunomodulators that, if used concomitantly with Skyrizi, disqualify authorization include: adalimumab, Bimzelx (bimekizumab-bkzx), Cimzia (certolizumab), Cosentyx (secukinumab), Enbrel (etanercept), Ilumya (tildrakizumab), Otezla (apremilast), Siliq (brodalumab), Sotyktu (deucravacitinib), Taltz (ixekizumab), Tremfya (guselkumab), ustekinumab, and other biologic or targeted therapies listed for specific indications (for example: Orencia (abatacept), Rinvoq (upadacitinib), Simponi (golimumab), Xeljanz/Xeljanz XR (tofacitinib), Entyvio (vedolizumab), Omvoh (mirikizumab-mrkz), Zeposia (ozanimod)).

Initial Authorization Rules — Initial authorization requires diagnosis and absence of concomitant targeted immunomodulator therapy

Initial authorization requires both an appropriate diagnosis for the requested indication and absence of concomitant targeted immunomodulator therapy.

Initial authorization rules: (1) Appropriate diagnosis for the requested indication (as listed for plaque psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis); (2) Patient is not receiving Skyrizi in combination with another targeted immunomodulator (examples listed per indication).

Authorization duration: 12 months

Reauthorization/Continuation — Reauthorization requires evidence of benefit

Reauthorization requires documentation of clinical benefit and absence of concomitant targeted immunomodulator therapy.

Reauthorization/Continuation: (1) Documentation of positive clinical response to Skyrizi therapy; (2) Patient is not receiving Skyrizi in combination with another targeted immunomodulator (examples listed per indication).

Authorization issued for 12 months; lack of documentation of benefit may result in denial

Reauthorization — Reauthorization duration information

Reauthorization period: Authorization will be issued for 12 months.

State mandates, federal requirements, and member benefit plan coverage may impact coverage and documentation requirements.

Provider Actions, Prior Authorization and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required. Skyrizi (risankizumab-rzaa) will be approved for initial authorization only when the member meets the applicable FDA‑indicated diagnosis criteria (e.g., moderate to severe plaque psoriasis; active psoriatic arthritis; moderately to severely active Crohn’s disease; moderately to severely active ulcerative colitis) and the patient is NOT receiving Skyrizi in combination with another targeted immunomodulator. Authorization will generally be issued for 12 months. State mandates and member benefit plan coverage may affect coverage and duration.

Authorization duration: 12 months (subject to state mandates and benefit plan terms)
Combination therapy exclusion: concurrent use with another targeted immunomodulator is a disqualifying condition

Documentation Required

Reauthorization — documentation of clinical response required

For reauthorization, documentation must demonstrate a positive clinical response to Skyrizi therapy. Lack of documentation of clinical improvement on reauthorization may result in denial of continued coverage.

Step Therapy and Supply Limits

Program rule	Details
Supply limits, Medical Necessity, and/or Step Therapy may apply according to program.
Notwithstanding Coverage Criteria, approvals may be based on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic; automated processes vary by program/therapeutic class.

Pre-approval controls	Implication for authorization
Supply limits, Medical Necessity, and/or Step Therapy may be in place and applied prior to approval.
Use of automated approval and re-approval processes may result in decisions based solely on prior claims/medication history, diagnosis codes (ICD-10), and/or claim logic; program variation applies.

Site of Care and Coverage Influences

Note

State/plan/federal rules may impact coverage and site‑of‑care

State mandates, federal regulatory requirements, member benefit plans, and other utilization management programs may affect coverage and the allowed site‑of‑care (including infusion center rules).

Check state and member plan rules for site‑of‑care restrictions or additional requirements.
Other UM programs may impose additional site‑of‑care limitations.

Background on Skyrizi

Skyrizi (risankizumab-rzaa) is an interleukin-23 antagonist indicated for the treatment of moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy. The agent is referenced as the drug subject to the authorization and reauthorization requirements in this policy.

Definitions

Skyrizi — Key definition and indications summary

DrugSkyrizi (risankizumab-rzaa)

Drug classInterleukin-23 antagonist (interleukin-23 inhibitor)

Indications coveredModerate to severe plaque psoriasis; active psoriatic arthritis; moderately to severely active Crohn's disease; moderately to severely active ulcerative colitis (adults)

Authorization durationAuthorization will be issued for 12 months

FormulationSubcutaneous (policy applies to subcutaneous formulations)

Targeted immunomodulator — definition and examples

Definition

Reauthorization / Continuation Criteria

Reauthorization/Continuation — Reauthorization requires evidence of benefit

Reauthorization requires documentation of clinical benefit and absence of concomitant targeted immunomodulator therapy.

Authorization issued for 12 months; lack of documentation of benefit may result in denial

Reauthorization — Reauthorization duration (authorization length and renewal notes)

Reauthorization period: Authorization will be issued for 12 months.

State mandates, federal requirements, and member benefit plan coverage may impact coverage and documentation requirements.

Coding and Claims

Note

Automated decisions may use diagnosis codes (ICD‑10) and prior claims to approve requests

Automated prior authorization decisions may reference submitted diagnosis codes (ICD‑10) and prior claims/medication history as the basis for approval; ensure accurate ICD‑10 coding to support automation.

Accurate diagnosis coding can enable automated approval pathways.
If diagnosis codes are missing or incorrect, automated approval may not be available.

Revision History

2025-10-01policy_effectiveLatest

Policy effective date: authorization will be issued for 12 months; state mandates, federal requirements, and member-specific benefit plan coverage may impact coverage and documentation requirements.

program_update

UnitedHealthcare notes that approvals may be based on prior claim/medication history, ICD-10 diagnosis codes, and/or claim logic; automated approval processes and supply limits or step therapy may apply.

OpenPayer

Skyrizi (risankizumab-rzaa) — Prior Authorization and Reauthorization Criteria (subcutaneous)

Coverage Criteria for Skyrizi (risankizumab-rzaa)

Provider Actions, Prior Authorization and Documentation

Step Therapy and Supply Limits

Site of Care and Coverage Influences

Background on Skyrizi

Definitions

Reauthorization / Continuation Criteria

Coding and Claims

Revision History