Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Preferred Agents:
The use of risankizumab-rzaa (Skyrizi) IV may be considered medically necessary when the following criteria are met:
For Crohn's Disease (CD):
- The individual must meet recommendations found in the FDA label or compendia (e.g., diagnosis, age, dosage, frequency, route); and
- The individual must have failed a three (3)-month trial of a TNF Inhibitor, as evidenced by paid claims or pharmacy printouts.
If approved, risankizumab-rzaa (Skyrizi) IV will be allowed as three (3) intravenous infusions over twelve (12) weeks.
Risankizumab-rzaa (Skyrizi) IV for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Codes
