Risankizumab-rzaa (Skyrizi™)

SELF ADMINISTRATION

Indications for Prior Authorization:
  • Treatment of adults with moderate to severe plaque psoriasis who are candidates for systemic therapy or phototherapy

Patients must meet the following criteria for the indication(s) above:
  • Patient is 18 years of age or older, AND
  • Prescribed by or in consultation with a dermatologist, AND
  • Chart note documentation is provided supporting diagnosis of moderate to severe plaque psoriasis confirmed by a dermatologist, AND
  • Psoriasis affects 10% or more of the body or psoriasis involves hands, feet, neck, or genitalia, AND
  • Patient has tried and failed topical therapy (e.g. Dovonex, Tazorac, other topical steroids), AND
  • Documented failure or clinically significant adverse effects to one of the following therapies alone or in combination, unless contraindicated
    • Methotrexate or (if methotrexate is contraindicated) cyclosporine, acitretin, or a trial with psoralen plus ultraviolet A light (PUVA)
The following conditions do not meet he criteria for use as established by WHA P&T committee:
  • All non-FDA approved uses not listed in the approved indications
Dosing:
  • 150 mg (2 syringes) subcutaneously at weeks 0 and 4, then once every 12 weeks thereafter

Approval:
  • Initial approval: 4 months to assess patient’s response
  • Renewal: 1 year if chart note documentation denotes a positive clinical response
Risk of Tuberculosis:

Patients should be evaluated for latent tuberculosis infection with a TB skin test. Treatment of latent tuberculosis infection should be initiated prior to therapy with Skyrizi™

Last review date: July 23, 2019