Subject: Specialty Quantity Limit Skyrizi 3049-H P2023a

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) 150 mg/mL   single-dose   prefilled   syringe/pen	1 syringe/pen   per 84 days	2 syringes/pens   per 28 days	Plaque psoriasis and   psoriatic arthritis   •   150 mg at weeks 0, 4,        and every 12 weeks        thereafter
Skyrizi   (risankizumab-   rzaa) 180   mg/1.2mL   single-dose   prefilled cartridge   with on-body   injector	1 cartridge per   56 days	N/A	Crohn’s disease,   maintenance   •   180 mg or 360 mg at        week 12 (four weeks        after the last        intravenous induction        dose), then every 8        weeks thereafter
Skyrizi   (risankizumab-   rzaa) 360   mg/2.4mL   single-dose   prefilled cartridge   with on-body    injector	1 cartridge per   56 days	N/A
Skyrizi   (risankizumab-   rzaa) 600   mg/10mL   single-dose vial	3 vials per 56 days	N/A	Crohn’s disease,   intravenous induction   •   600 mg at weeks 0, 4,        and 8

  *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.; March 2023.

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.

August 13, 2023