Subject: Specialty Quantity Limit Skyrizi 3049-H P2022

Drug

SKYRIZI  (risankizumab-rzaa)

Policy:

       I.  PROGRAM DESCRIPTION

            The standard limit is designed to allow a quantity sufficient for
            the most common uses of the medication. If the member’s
            plan allows a quantity limit exception review for the requested
            medication, coverage of an additional quantity may be
            provided up to the exception limit with prior authorization.

 

     II.  COVERED QUANTITIES

Medication	Standard Limit	Exception Limit*	FDA-recommended dosing
Skyrizi  (risankizumab- rzaa)  75 mg/0.83 mL  single-dose  prefilled syringe	2 syringes  per 84 days	4 syringes per 28 days	150 mg at weeks 0, 4, and  every 12 weeks thereafter
Skyrizi  (risankizumab-rzaa)  150 mg/mL  single-dose prefilled  syringe/pen	1 syringe  per 84 days	2 syringes per 28 days

*Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity Exception Criteria for approval.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Skyrizi [package insert]. North Chicago, IL: AbbVie Inc.; January 2022.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

June 26, 2022