Skyrizi (risankizumab-rzaa) — United Healthcare

moderate to severe plaque psoriasis

Initial criteria

Diagnosis of moderate to severe plaque psoriasis
AND one of the following:
A) All of the following:
i. ≥ 3% body surface area involvement, palmoplantar, facial, genital involvement, or severe scalp psoriasis
AND ii. History of failure to one of the following topical therapies, unless contraindicated or clinically significant adverse effects:
- Corticosteroids (e.g., betamethasone, clobetasol, desonide)
- Vitamin D analogs (e.g., calcitriol, calcipotriene)
- Tazarotene
- Calcineurin inhibitors (e.g., tacrolimus, pimecrolimus)
- Anthralin
- Coal tar
AND iii. History of failure to a 3-month trial of methotrexate at maximally indicated dose, unless contraindicated or clinically significant adverse effects
OR B) Patient has been previously treated with a targeted immunomodulator FDA-approved for plaque psoriasis (e.g., adalimumab, Cimzia, Cosentyx, Enbrel, Otezla, Sotyktu, Tremfya, ustekinumab)
OR C) Both of the following:
i. Patient is currently on Skyrizi therapy as documented by claims history or medical records
AND ii. Patient has not received a manufacturer supplied sample or any form of assistance from the Abbvie Skyrizi Complete program
AND Patient is not receiving Skyrizi in combination with another targeted immunomodulator [list as in policy]
AND Prescribed by or in consultation with a dermatologist

Documentation of positive clinical response to Skyrizi therapy
AND Patient is not receiving Skyrizi in combination with another targeted immunomodulator [list as in policy]

12 months