Medical Policy
Effective Date:06/01/2023 Title:Skyrizi IV
Revision Date: Document:BI718:00
CPT Code(s):J2327
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Skyrizi (risankizumab) requires prior authorization. Skyrizi in the subcutaneous dosage form will be covered under the pharmacy benefit and initial PA requests will be submitted to MagellanRx. Skyrizi IV (for Crohn’s disease) will be considered by QualChoice.

2)    Skyrizi is used treat plaque psoriasis, psoriatic arthritis, and Crohn’s disease.
Medical Statement

Skyrizi (subcutaneous dosage form) requires PA but is covered under the pharmacy benefit and will use the MagellanRx PA criteria.

 

Skyrizi (IV dosage) form is considered medically necessary for members meeting ALL of the following criteria:

 

1)    Diagnosis of moderately to severely active Crohn’s disease

2)    Prescribed by or in consultation with a gastroenterologist

3)    Members has failed at least one immunomodulator (e.g. azathioprine, 6-mercaptopurine, methotrexate) at up to maximally indicated doses (unless clinically significant adverse effects are experienced or all are contraindicated).

4)    Member experiences at least one of the following:

a.    Frequent diarrhea and abdominal pain

b.    At least 10% weight loss

c.    Complications such as obstruction, fever, abdominal mass

d.    Abnormal lab values (e.g. C-reactive protein)

e.    CD Activity Index (CDAI) greater than 220

5)    Will be administered as an intravenous induction dose.

·         If approved for IV induction dosing through medical benefit, PA for subsequent subcutaneous dosing will be entered in the pharmacy benefit claims system as well.

 

Codes Used In This BI:

 

1)    J2327 – Injection, risankizumab-rzaa, intravenous, 1mg
Limits
Intentially left empty
Reference

1)    Skyrizi Prescribing Information. North Chicago, IL: Abbvie Inc.; September 2022.

2)    Feuerstein JD, Ho EY, Shmidt E, et al. AGA Clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn’s disease. Gastroenterology 2021; 160:2496-2508.
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.