Skyrizi (risankizumab) Letter of Medical Necessity
Skyrizi (risankizumab) is increasingly used as a high-efficacy IL-23 option but typically requires documented failure of preferred therapies. LMNs should address payer-specific step therapy and severity criteria.
FDA-Approved Indications
- ● plaque psoriasis
- ● psoriatic arthritis
- ● Crohn's disease
- ● ulcerative colitis
Why Skyrizi Prior Authorization Gets Denied
The most common denial reasons across major payers:
- 1. Step therapy: TNF or IL-17 not tried first
- 2. Severity scoring not documented
- 3. Off-label dosing schedule
- 4. Concurrent biologic
What to Include in a Skyrizi Letter of Medical Necessity
Document diagnosis severity (PASI, BSA, partial Mayo, SES-CD), prior biologic and conventional therapy trials, contraindications to preferred alternatives, and the clinical rationale for selective IL-23 blockade.
Key clinical evidence to cite:
- ✓ UltIMMa-1, UltIMMa-2, IMMvent, IMMhance trials
- ✓ KEEPsAKE program for PsA
- ✓ ADVANCE and MOTIVATE for Crohn's
Relevant guidelines:
- 📖 AAD-NPF 2019 Psoriasis Guidelines
- 📖 AGA 2020 IBD Guidelines
Skyrizi Prior Authorization Criteria
Standard criteria across major US payers for Skyrizi. Specific criteria vary by plan — RxCheckUp tailors each LMN to your patient's exact payer policy.
Typical step therapy requirements:
- → Step therapy: TNF or IL-17 not tried first
Required documentation:
- ✓ ICD-10 diagnosis code with specificity
- ✓ Prior therapy history with dates, doses, and discontinuation reasons
- ✓ Specialist evaluation (where applicable)
- ✓ Baseline disease activity or biomarker results
- ✓ Clinical rationale citing FDA labeling or guidelines
Approval details:
Initial approval: typically 6 months. Renewal: 12 months with documented clinical response.
Payers Covering Skyrizi
RxCheckUp tailors each LMN to the specific payer's medical policy and step therapy requirements:
Skyrizi Prior Authorization FAQ
Why was my Skyrizi prior authorization denied?
The most common denial reasons for Skyrizi are: Step therapy: TNF or IL-17 not tried first; Severity scoring not documented; Off-label dosing schedule; Concurrent biologic.
What should a Skyrizi Letter of Medical Necessity include?
Document diagnosis severity (PASI, BSA, partial Mayo, SES-CD), prior biologic and conventional therapy trials, contraindications to preferred alternatives, and the clinical rationale for selective IL-23 blockade.
Which payers cover Skyrizi?
Skyrizi is covered by major US payers including UnitedHealthcare, Aetna, Cigna, BCBS, Medicare Part D, though formulary tier and prior authorization criteria vary.