Limited Coverage Drugs - risankizumab

Generic Name

risankizumab

Strength

75 mg/0.83 mL

Form

subcutaneous injection solution
 
Special Authority Criteria Approval Period

For the treatment of moderate to severe plaque psoriasis, according to established criteria described in Special Authority request form 5380, when prescribed by a dermatologist.

First approval: 16 weeks

Renewal: 1 year

Practitioner Exemptions

  • None

Special Notes

  • None

Special Authority Request Forms

5380 - Biologics for Moderate to Severe Plaque Psoriasis (PDF)

5379 - Psoriasis Area and Severity Index - PASI Worksheet (PDF)