Subject: Specialty Quantity Limit Skyrizi 3049-H P2024

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.; January 2024.

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 09, 2024