Skyrizi — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years
• According to the prescriber, the patient will receive three induction doses with Skyrizi intravenous within 3 months of initiating therapy with Skyrizi subcutaneous
• Patient meets ONE of the following: a) Patient has had a trial of one systemic agent for ulcerative colitis; OR b) Patient has pouchitis and has tried an antibiotic, probiotic, corticosteroid enema, or mesalamine enema
• The medication is prescribed by or in consultation with a gastroenterologist

Reauthorization criteria

• Patient has been established on the requested drug for at least 6 months
• Patient meets at least one of the following: a) When assessed by at least one objective measure, patient experienced a beneficial clinical response from baseline; OR b) Compared with baseline, patient experienced an improvement in at least one symptom such as decreased pain, fatigue, stool frequency, and/or decreased rectal bleeding

Approval duration

initial 6 months, reauth 1 year