By Counterforce Health Team in Skyrizi (risankizumab) —

Get Skyrizi (Risankizumab) Covered by Aetna CVS Health in Virginia: Complete Prior Authorization and Appeals Guide

Quick Answer: Getting Skyrizi Covered by Aetna CVS Health in Virginia

Aetna CVS Health requires prior authorization for Skyrizi (risankizumab) with step therapy mandates, typically requiring documented TNF inhibitor failure. Submit PA requests via Availity portal at least 2 weeks in advance. If denied, Virginia's State Corporation Commission Bureau of Insurance provides external review within 120 days using Form 216-A. First step today: Gather your insurance card, prior therapy records, and PASI/BSA documentation, then contact your dermatologist to initiate the PA process.

Table of Contents

  1. Set Your Goal: Understanding Aetna's Requirements
  2. Visit Preparation: Documenting Your Case
  3. Evidence Kit: Clinical Documentation
  4. Medical Necessity Letter Structure
  5. Peer-to-Peer Review Support
  6. After Your Visit: Tracking and Follow-Up
  7. Appeals Process in Virginia
  8. Common Denial Reasons and Solutions
  9. Cost Assistance Programs
  10. Frequently Asked Questions

Set Your Goal: Understanding Aetna's Requirements

Skyrizi (risankizumab) is an IL-23 inhibitor approved for moderate-to-severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis. Aetna CVS Health requires prior authorization for this specialty biologic, with specific coverage criteria you'll need to meet.

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed
Prior Authorization Pre-approval required before filling Complete PA form via provider
Step Therapy TNF inhibitor failure typically required Chart notes showing inadequate response to adalimumab, etanercept, or infliximab
Severity Documentation Moderate-to-severe psoriasis PASI ≥12, BSA ≥10%, or sPGA ≥3
Prescriber Requirements Board-certified specialist preferred Dermatologist, rheumatologist, or gastroenterologist
Diagnosis Confirmation ICD-10 codes required L40.0 (plaque psoriasis), M07.3 (psoriatic arthritis), etc.

Working with your doctor is essential because over 95% of eligible PAs approve within 24 hours when submitted correctly through CVS Caremark's system.

Visit Preparation: Documenting Your Case

Before your appointment, create a comprehensive timeline of your psoriasis journey. This preparation will help your doctor write a compelling medical necessity letter and navigate Aetna's requirements efficiently.

Symptom and Treatment Timeline

Document these key elements:

Disease Severity Markers:

  • Body surface area (BSA) affected (estimate percentage)
  • Areas involved (face, hands, feet, genitals are considered high-impact)
  • PASI score if previously calculated
  • Dermatology Life Quality Index (DLQI) impact

Prior Treatments and Outcomes:

  • Topical therapies tried (corticosteroids, vitamin D analogs, calcineurin inhibitors)
  • Duration of each treatment and specific reasons for discontinuation
  • Phototherapy attempts (UVB, PUVA) if applicable
  • Previous systemic therapies, especially TNF inhibitors

Functional Impact Documentation:

  • Work or school limitations
  • Sleep disruption from itching or pain
  • Social isolation or depression
  • Physical limitations affecting daily activities
Tip: Take photos of affected areas before your visit. Visual documentation can strengthen your case, especially for hard-to-describe locations or severity.

Evidence Kit: Clinical Documentation

Your dermatologist will need comprehensive clinical evidence to support the prior authorization request. Help them gather these essential documents:

Required Clinical Documentation

Laboratory Results:

  • Complete blood count (CBC) with differential
  • Comprehensive metabolic panel
  • Liver function tests
  • Tuberculosis screening (QuantiFERON-Gold or TST)
  • Hepatitis B and C screening

Imaging Studies (if applicable):

  • Chest X-ray for TB screening
  • Joint imaging for psoriatic arthritis cases

Treatment History Records:

  • Pharmacy records showing filled prescriptions
  • Previous dermatology visit notes
  • Documentation of treatment failures or intolerances
  • Allergy information and contraindications

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's requirements.

Medical Necessity Letter Structure

A well-structured medical necessity letter is crucial for Aetna approval. AbbVie provides official templates for healthcare providers, but understanding the key components helps you support your doctor's efforts.

Essential Letter Components

Patient Information Section:

  • Full name, date of birth, member ID
  • Primary diagnosis with ICD-10 code (L40.0 for plaque psoriasis)
  • Current symptoms and functional limitations

Clinical Justification:

  • Disease severity documentation (PASI ≥12, BSA ≥10%, or crucial area involvement)
  • Prior treatment failures with specific details
  • Contraindications or intolerances to alternative therapies
  • Why Skyrizi is medically necessary for this patient

Supporting Evidence:

  • FDA prescribing information citations
  • Clinical trial data (ULTIMMA-1/2 showing 75% PASI 90 response at week 16)
  • Professional society guidelines supporting biologic use
  • Monitoring plan for safety

Provider Credentials:

  • Board certification in relevant specialty
  • NPI number and practice information
  • Statement of medical necessity and prescriber responsibility

Peer-to-Peer Review Support

If Aetna initially denies your prior authorization, you can request a peer-to-peer review where your doctor discusses the case directly with an Aetna medical director. This process must be initiated within 14 calendar days of the denial notice.

Preparing for Peer-to-Peer Review

Create a One-Page Case Summary:

  • Patient age, diagnosis, BSA percentage affected
  • Specific prior therapies with dates, durations, and failure reasons
  • Functional limitations and risks of treatment delay
  • Clear explanation of why alternatives are insufficient

Key Talking Points for Your Doctor:

  • "This patient meets all Aetna criteria for Skyrizi coverage"
  • "Documented failures of required step therapies with specific dates and outcomes"
  • "Current treatment options are inadequate for disease control"
  • "Expected clinical benefits based on trial data and patient profile"

Supporting Documentation Ready:

  • Complete medical records
  • Laboratory results and imaging
  • Prior authorization denial letter
  • Treatment timeline with objective measures

After Your Visit: Tracking and Follow-Up

Once your doctor submits the prior authorization, active tracking ensures timely processing and identifies issues early.

Follow-Up Timeline

Days 1-3: Confirm PA submission

  • Verify submission through Aetna provider portal
  • Obtain confirmation number or reference ID
  • Ensure all required documents were included

Days 5-10: Status monitoring

  • Check portal every 2-3 business days
  • Contact provider office if no status updates
  • Prepare for potential requests for additional information

Days 10-14: Proactive communication

  • Call Aetna if decision is pending beyond standard timeframe
  • Ensure provider office is monitoring for requests
  • Prepare appeal documentation if denial seems likely

Day 15+: Escalation planning

  • If denied, immediately request peer-to-peer review
  • Begin gathering additional supporting evidence
  • Consider expedited appeal if treatment delay poses health risks

Appeals Process in Virginia

Virginia provides robust consumer protections for insurance appeals through the State Corporation Commission Bureau of Insurance. Understanding this process gives you powerful options if Aetna denies coverage.

Internal Appeals with Aetna

Standard Appeal Process:

  • Submit within 180 days of denial notice
  • Use Aetna's online portal or written appeal
  • Include additional clinical documentation
  • Decision typically within 30-45 days

Expedited Appeals:

  • Available for urgent medical situations
  • Decision within 72 hours for urgent cases
  • Requires physician certification of medical urgency
  • Can be submitted by phone for immediate processing

Virginia External Review Process

If Aetna upholds their denial after internal appeals, Virginia's external review process provides independent oversight through the State Corporation Commission Bureau of Insurance.

Key External Review Details:

Review Type Timeline Decision Authority
Standard 45 days from IRO receipt Independent medical experts
Expedited 72 hours for urgent cases Board-certified specialists
Cancer Treatment Special expedited process available No internal appeal requirement

Submission Requirements:

Contact Information:

Note: Virginia's external review is free and the decision is binding on Aetna. Many patients have successfully obtained coverage for specialty medications through this process.

Common Denial Reasons and Solutions

Understanding why Aetna might deny Skyrizi helps you prepare stronger initial submissions and effective appeals.

Typical Denial Scenarios and Responses

Denial Reason How to Overturn
"Step therapy not completed" Document specific TNF inhibitor trials with dates, dosing, duration, and objective failure measures
"Not medically necessary" Provide PASI scores ≥12, BSA documentation, functional impact measures (DLQI), and guideline citations
"Insufficient documentation" Submit complete treatment history, laboratory results, and detailed provider assessment
"Experimental/investigational" Cite FDA approval, clinical trial data, and professional society treatment guidelines
"Non-formulary medication" Request formulary exception with comparative effectiveness data and alternative therapy failures

Strengthening Your Appeal

When appealing denials, Counterforce Health's platform can help identify the specific denial basis and draft targeted rebuttals that align with Aetna's own coverage policies, incorporating the right clinical evidence and procedural requirements.

Appeal Enhancement Strategies:

  • Include peer-reviewed studies supporting Skyrizi effectiveness
  • Provide economic analyses showing long-term cost benefits
  • Document quality of life improvements expected with treatment
  • Submit letters of support from specialty societies if applicable

Cost Assistance Programs

Even with insurance coverage, Skyrizi can involve significant out-of-pocket costs. Several programs can help reduce your financial burden.

Manufacturer Support Programs

AbbVie Complete:

  • Copay assistance for eligible patients
  • Navigation support for insurance issues
  • Patient education and injection training
  • Phone: 1-844-SKYRIZI (1-844-759-7494)

Eligibility Requirements:

  • Commercial insurance coverage (not Medicare/Medicaid)
  • Prescription for approved indication
  • Income and insurance verification

Additional Financial Resources

Patient Assistance Foundations:

  • National Psoriasis Foundation assistance programs
  • HealthWell Foundation grants for autoimmune conditions
  • Patient Access Network Foundation specialty drug support
  • CancerCare copay assistance (for oncology indications)

State-Specific Programs in Virginia:

  • Virginia Medicaid coverage for eligible individuals
  • Virginia Health Insurance Premium and Cost Sharing Reduction Program
  • Community health center sliding fee scales

Frequently Asked Questions

How long does Aetna CVS Health prior authorization take for Skyrizi in Virginia? Standard processing is typically 30-45 days, but over 95% of properly submitted requests are approved within 24 hours. Expedited reviews for urgent cases are completed within 72 hours.

What if Skyrizi is not on Aetna's formulary? You can request a formulary exception by documenting medical necessity and failure of preferred alternatives. Include comparative effectiveness data and cost-benefit analyses when possible.

Can I appeal if I haven't tried all step therapy requirements? Yes, if you have documented contraindications, allergies, or medical reasons why step therapy medications are inappropriate. Your doctor must provide clinical justification for skipping required steps.

Does Virginia external review cost anything? No, Virginia's external review process is completely free to consumers. The State Corporation Commission covers all costs associated with independent medical review.

What happens if external review upholds Aetna's denial? The decision is final and binding. However, you may have other options including employer plan appeals (for self-funded plans), legal consultation, or exploring alternative treatment approaches.

How do I know if my plan is eligible for Virginia external review? Virginia-issued plans and self-funded employer plans that opt-in are eligible. Contact the Bureau of Insurance at 1-877-310-6560 to verify eligibility for your specific plan.

Can I request expedited appeals in Virginia? Yes, if your doctor certifies that waiting for standard review could seriously jeopardize your health. Expedited external reviews are decided within 72 hours for urgent cases.

What documentation should I keep throughout this process? Maintain copies of all correspondence, denial letters, medical records, appeal submissions, confirmation numbers, and dates of all communications. This documentation is crucial for external review if needed.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with qualified professionals for insurance and legal matters. Coverage policies and state regulations may change; verify current requirements with official sources.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.