Diagnosis: Psoriasis.
Treatment: Skyrizi Pen INJ 150mg/mL, Pre-service.
The insurer denied the Skyrizi Pen INJ 150mg/mL, Pre-service.
The denial is overturned.

The patient is a male with psoriasis to the trunk, extremities, face and nails, 30% body surface area (BSA), treated with multiple topicals. The provider is requesting Skyrizi. The health plan requires a trial and failure to methotrexate and formulary alternatives Humira, Enbrel, Cimzia, Ilumya and Cosentyx. The patient has a strong family history of malignancy.

Yes, Skyrizi is medically necessary.
Skyrizi meets medical necessity as it is considered within good standards of acceptable medical practice. Skyrizi is an approved, appropriate and effective medication for psoriasis. A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. Skyrizi is among the most effective therapies for psoriasis according to current peer-reviewed literature and does not carry a risk of malignancy, making it a highly appropriate choice for this patient.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.