ACCESS & REIMBURSEMENT

BENEFIT VERIFICATION & PRIOR AUTHORIZATION SUPPORT FOR MEDICAL AND PHARMACY BENEFITS

skyrizi complete

Enroll your patients into Complete for support and potential savings for your patients

One J-Code for both SKYRIZI UC
and Crohn’s reimbursement

J-Code for SKYRIZI: J2327

Find an infusion center

You can find infusion centers for your SKYRIZI patients by using SKYRIZILocator.com.

SPECIALTY PHARMACIES AND DISTRIBUTORS

A complete list of specialty pharmacies that provide On-Body Injector (OBI) support for SKYRIZI.

WHOLESALE AND SPECIALTY DISTRIBUTORS

A complete list of wholesalers and specialty
distributors that provide intravenous (IV) infusion support for SKYRIZI.

SKYRIZI NDCs

Two single-dose vials are needed per induction dose for UC. Order two cartons of NDC 0‍0‍7‍4‍-‍5‍0‍1‍5‍-‍0‍1 for each induction dose that is needed.

Single-dose Vial
600 mg/10.0 mL

0‍0‍7‍4‍-‍5‍0‍1‍5‍-‍0‍1
Carton of 1

Single-dose Prefilled Cartridge
With On-Body Injector (OBI)
180 mg/1.2 mL

007‍4-1‍065‍-0‍1
Kit

Single-dose Prefilled Cartridge
With OBI

360 mg/2.4 mL

0‍0‍7‍4‍-‍1‍0‍7‍0‍-‍0‍1
Kit

NDC=National Drug Code.

ACCESS AND REIMBURSEMENT FORMS

Along with support from SKYRIZI Complete, you can use the forms here to help patients with access and coverage for SKYRIZI. For support in person or over the phone, call your access specialist at 1.877.COMPLETE (1.877.266.7538).

Prior Authorization Instructions

Follow this helpful checklist to request coverage of SKYRIZI.

Download Instructions (PDF)

SKYRIZI Appeal Letter (Example)

Appeal a denied claim for SKYRIZI.

Instructions (PDF)

Download Appeal Letter (.docx)

SKYRIZI Letter of Medical Necessity

Establish the medical necessity of SKYRIZI.

Instructions (PDF)

Download Medical Necessity Letter (.docx)

SKYRIZI Letter of Medical Exception

Download Medical Exception Letter (.docx)

Formulary Exception Letter

Request a formulary exception to allow coverage for SKYRIZI.

Instructions (PDF)

Tiered Exception Letter

Request lower cost sharing for SKYRIZI as a preferred medication.

Instructions (PDF)

Download Tiered Exception Letter (.docx)

HIPAA Authorization

Allow patients to authorize the release of health information related to their treatment with SKYRIZI.

Download HIPAA Form (PDF)

Assist patients with SKYRIZI IV costs

Utilize this form as a guide when submitting patient claims for reimbursement for eligible, commercially insured patients using the SKYRIZI Complete Savings Card.

Download Reimbursement Form (PDF)

HIPAA=Health Insurance Portability and Accountability Act.

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