What the Prior Auth Letter Writer actually produces

RE: Prior Authorization Request for [Patient] Member ID: [Member ID — verify] Date of Birth: [DOB] Plan: Blue Cross Blue Shield of Illinois

To the Medical Director:

I am writing to request prior authorization for Skyrizi (risankizumab), [dose — verify], for the treatment of moderate to severe plaque psoriasis in the above-referenced patient. This request is submitted under standard review timelines.

Diagnosis and Disease Severity: The patient carries a diagnosis of moderate to severe plaque psoriasis. Per the clinical documentation provided, the patient's Psoriasis Area and Severity Index (PASI) score is 18 (input-derived value); this should be corroborated against the current clinical assessment on file.

Prior Therapies and Rationale for Inadequacy:

• Methotrexate — discontinued due to hepatotoxicity. This adverse event represents a clinically significant safety concern precluding continuation or rechallenge with this agent.
• Adalimumab (Humira) — trialed for six months with inadequate clinical response. Per the clinical rationale supplied, this constitutes failure of a TNF-alpha inhibitor.

The patient has therefore failed one conventional systemic agent (discontinued for toxicity) and one biologic agent (inadequate response) prior to this request, consistent with a step-therapy history involving both a conventional and a biologic therapy.

Clinical Rationale for Medical Necessity: The treating clinician has indicated that Skyrizi, described as an IL-23 inhibitor per the submitted clinical rationale, is appropriate given the documented failure of a TNF-alpha inhibitor. The clinical rationale references management consistent with AAD-NPF guideline principles for sequencing therapy after biologic failure; the specific guideline recommendation and citation should be verified against current published guidance [verify]. Given the patient's toxicity-related discontinuation of methotrexate and inadequate response to adalimumab despite an adequate trial duration, continuation of conventional or same-class biologic therapy is not clinically supported, and a therapy with a distinct mechanism of action is warranted.

Patient-Specific Factors:

• Documented hepatotoxicity with methotrexate precludes reuse of this agent.
• Six-month trial of adalimumab without adequate clinical response indicates failure of an adequate therapeutic trial.
• Current PASI score of 18 (input-derived) reflects ongoing moderate-to-severe disease burden.
• Allergy history: [not provided — verify].
• Other comorbidities/contraindications: [not provided — verify].

Based on the above, the supplied documentation supports a history of treatment failure with both a conventional systemic agent and a TNF-alpha inhibitor biologic, and supports consideration of an alternative-mechanism biologic. The specific dose, treatment duration goals, and full guideline citation should be confirmed by the prescribing provider and are not asserted here beyond what is documented.

I respectfully request expedited review and approval of this prior authorization request. Please contact my office with any additional questions or requests for supporting documentation.

Sincerely,

[Prescriber Name], [Credentials] [Practice Name] [Phone Number] [Fax Number] [NPI Number]

• Methotrexate discontinued due to hepatotoxicity — precludes rechallenge, per submitted history
• Adalimumab (TNF-alpha inhibitor) trialed for 6 months with inadequate clinical response — meets criterion of failed adequate trial
• PASI score of 18 (input-derived) indicates ongoing moderate-to-severe disease activity
• Clinical rationale references AAD-NPF guideline-consistent sequencing after biologic failure — specific citation to be verified [verify]
• Requested agent (risankizumab) described in clinical rationale as an IL-23 inhibitor, representing a distinct mechanism from prior TNF-alpha inhibitor therapy
• Dose and treatment duration not specified in available documentation — [dose — verify]
• Allergy and comorbidity status not provided — [not provided — verify]