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)
