By Counterforce Health Team in Skyrizi (risankizumab) —

Do You Qualify for Skyrizi (risankizumab) Coverage by Blue Cross Blue Shield in New York? Decision Tree & Appeal Guide

Answer Box

Getting Skyrizi (risankizumab) covered by Blue Cross Blue Shield in New York requires prior authorization with documented TNF inhibitor failure for IBD, or moderate-to-severe psoriasis (PASI ≥10-12, BSA ≥3%) for dermatology indications. Submit PA through your provider via Anthem's digital portal or fax with clinical documentation. If denied, file internal appeal within 60 days, then external appeal through NY Department of Financial Services within 4 months. First step today: Gather your diagnosis records, prior treatment history, and insurance card to verify your Blue Cross Blue Shield plan's specific formulary requirements.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If You're Likely Eligible: Documentation Checklist
  4. If You're Possibly Eligible: Next Steps
  5. If You're Not Yet Eligible: Alternatives
  6. If Denied: New York Appeal Process
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & Solutions
  9. Costs & Patient Support
  10. FAQ

How to Use This Guide

This decision tree helps you determine your likelihood of getting Skyrizi (risankizumab) covered by Blue Cross Blue Shield in New York. Work through each section based on your current situation. If you're unsure about any medical details, consult your prescribing physician.

Important: Blue Cross Blue Shield operates as 33 independent plans. While this guide covers common requirements across BCBS plans, always verify specific criteria with your individual plan.

Eligibility Triage: Do You Qualify?

Step 1: Confirm Your Diagnosis

Skyrizi is FDA-approved for:

  • Moderate-to-severe plaque psoriasis (adults)
  • Active psoriatic arthritis (adults)
  • Moderately to severely active Crohn's disease (adults)
  • Moderately to severely active ulcerative colitis (adults)

Step 2: Check Disease Severity Requirements

For Psoriasis:

  • PASI score ≥10-12 (plan-specific)
  • Body surface area (BSA) ≥3% OR involvement of sensitive areas (face, hands, feet, genitals)
  • Failed conventional therapy (topicals, phototherapy)

For IBD (Crohn's/UC):

  • Documented failure of TNF inhibitor (adalimumab, infliximab, certolizumab) for ≥3 months
  • OR failure of conventional therapy (corticosteroids, immunomodulators)
  • Age ≥18 years

Step 3: Safety Screening Complete?

  • Up-to-date vaccinations
  • TB screening completed and treated if positive
  • No active infections
  • Baseline liver function tests obtained
Note: Based on BCBS affiliate policies, most plans require TNF inhibitor failure for IBD indications.

If You're Likely Eligible: Documentation Checklist

Required Documents for PA Submission

Clinical Documentation:

  • Current diagnosis with ICD-10 codes
  • Disease severity assessment (PASI score, BSA percentage, or IBD activity measures)
  • Prior treatment history with dates, doses, and outcomes
  • TB screening results (QuantiFERON or TST)
  • Baseline laboratory values (CBC, liver function)
  • Vaccination records

Administrative Requirements:

  • Completed prior authorization form
  • Prescriber DEA and NPI numbers
  • Patient insurance information and member ID

Submission Process

  1. Provider submits PA via Anthem's digital portal or fax
  2. Timeline: Standard review takes 5-7 business days
  3. Expedited review: Available if delay would seriously jeopardize health (72-hour decision)

If You're Possibly Eligible: Next Steps

Additional Testing Needed

For Psoriasis:

  • Obtain formal PASI assessment from dermatologist
  • Document BSA percentage with photos if possible
  • Trial and document failure of conventional therapies

For IBD:

  • Confirm TNF inhibitor trial duration and dosing
  • Obtain objective disease activity measures (colonoscopy, imaging, biomarkers)
  • Document contraindications to preferred therapies if applicable

Timeline to Re-apply

Plan to resubmit PA within 30-60 days after obtaining additional documentation. Keep detailed records of all treatments attempted.

If You're Not Yet Eligible: Alternatives

Step Therapy Options

For Psoriasis:

  • Methotrexate
  • Cyclosporine
  • Acitretin
  • Phototherapy (PUVA, narrowband UVB)

For IBD:

  • TNF inhibitors (Humira, Remicade, Cimzia)
  • Vedolizumab (Entyvio)
  • Ustekinumab (Stelara)

Preparing for Exception Requests

Document why alternatives are inappropriate:

  • Contraindications
  • Previous adverse reactions
  • Drug interactions
  • Clinical urgency

If Denied: New York Appeal Process

Level 1: Internal Appeal

Timeline: File within 60 days of denial Process: Submit through BCBS member portal or by mail Decision: 30 days for standard, 72 hours for expedited

Level 2: External Appeal Through NY DFS

Who qualifies: NY-regulated health plans (most commercial BCBS plans) Timeline: File within 4 months of final internal denial Process:

  1. Complete NY External Appeal Application
  2. Submit supporting clinical evidence
  3. Fax to 800-332-2729 or mail to DFS

Decision Timeline: 30 days standard, 72 hours expedited Cost: $25 (waived for financial hardship, refunded if you win)

Get Free Help

Community Health Advocates provides free assistance with appeals. Call 888-614-5400 (Monday-Friday, 9 a.m.-4 p.m.) for one-on-one support navigating the appeals process.

Coverage Requirements at a Glance

Requirement Psoriasis IBD Where to Document
Prior Auth Yes Yes Provider portal/fax
Age Limit ≥18 years ≥18 years Medical records
Severity Threshold PASI ≥10-12, BSA ≥3% Moderate-severe active disease Clinical assessment
Step Therapy Conventional therapy failure TNF inhibitor failure Treatment history
Safety Screening TB, vaccines, labs TB, vaccines, labs Test results
Quantity Limits Per label dosing 11 weeks initial (IV induction) Prescription

Common Denial Reasons & Solutions

Denial Reason Solution Documentation Needed
"Not medically necessary" Submit severity documentation and treatment history PASI scores, BSA photos, prior therapy records
"Step therapy not met" Document adequate trials of required medications Prescription records, physician notes on failures
"Insufficient clinical information" Provide complete medical records Specialist consultation notes, lab results
"Non-formulary" Request formulary exception Medical necessity letter comparing alternatives

Costs & Patient Support

Manufacturer Support Programs

AbbVie Complete: Provides copay assistance and patient support services. Eligible patients may pay as little as $5 per month. Visit abbviecomplete.com or call 1-800-2ABBVIE.

Foundation Assistance

  • Patient Access Network Foundation: Provides grants for specialty medications
  • HealthWell Foundation: Offers copay assistance for eligible conditions
  • Good Days: Financial assistance for chronic disease treatments

FAQ

How long does BCBS prior authorization take in New York? Standard PA decisions are made within 5-7 business days. Expedited reviews (for urgent medical needs) are completed within 72 hours.

What if Skyrizi is non-formulary on my BCBS plan? You can request a formulary exception by having your doctor submit medical necessity documentation explaining why covered alternatives won't work for your condition.

Can I request an expedited appeal in New York? Yes. If waiting for a standard appeal decision could seriously jeopardize your health, you can request expedited review with a 72-hour decision timeline through NY DFS.

Does step therapy apply if I failed TNF inhibitors outside New York? Yes. BCBS plans typically accept documentation of prior treatment failures from any provider, regardless of location, as long as the clinical records are complete.

What happens if I can't afford the $25 external appeal fee? New York waives the fee for financial hardship cases and Medicaid enrollees. You can request a fee waiver when submitting your external appeal application.

How do I find my specific BCBS plan's formulary? Check your member portal or call the member services number on your insurance card. Each BCBS plan maintains its own formulary and PA requirements.

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for specialty medications like Skyrizi. Our platform analyzes denial letters, identifies specific coverage criteria, and generates evidence-backed appeals tailored to each payer's requirements. We help patients, clinicians, and pharmacies navigate complex prior authorization processes and appeal procedures.

When facing a Skyrizi denial from Blue Cross Blue Shield, having expert support can make the difference between approval and ongoing treatment delays. Counterforce Health provides the clinical expertise and payer knowledge needed to craft compelling appeals that address each plan's specific medical necessity requirements.

From Our Advocates: We've seen many Skyrizi appeals succeed when providers include objective severity measures and document specific reasons why step therapy medications failed or caused adverse effects. The key is addressing the payer's exact denial reasons with clinical evidence rather than general statements about treatment need. This approach has helped numerous patients access their prescribed therapy.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact your insurance plan directly to verify current coverage policies. For official appeal assistance in New York, contact the NY Department of Financial Services or Community Health Advocates.

Sources & Further Reading

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