By Counterforce Health Team in Skyrizi (risankizumab) —

Get Skyrizi (Risankizumab) Covered by Cigna in Michigan: Complete Prior Authorization and Appeals Guide

Quick Answer: Skyrizi (risankizumab) requires prior authorization from Cigna in Michigan, typically with step therapy requiring TNF inhibitor failure. Submit PA electronically via CoverMyMeds or call 1-800-882-4462. If denied, file internal appeal within 180 days, then external review with Michigan DIFS within 127 days. Your prescriber must document disease severity (PASI ≥12 for psoriasis, CDAI >220 for Crohn's) and prior treatment failures.

Table of Contents

Coverage Basics

Is Skyrizi covered by Cigna? Yes, but with restrictions. Skyrizi (risankizumab) is listed on Cigna's 2024 formulary as a specialty tier medication requiring prior authorization and step therapy.

Which Cigna plans cover it? Most Cigna commercial and Medicare plans include Skyrizi, but coverage varies by specific benefit design. Check your plan's formulary or call member services to confirm.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Doctor must get approval before filling Cigna PA Forms
Step Therapy Must try TNF inhibitor first Cigna formulary policy
Specialty Tier Higher copay/coinsurance Plan benefit summary
Quantity Limits 1 kit per 84 days (75mg), 1 pen per 84 days (150mg) Cigna Quantity Limits Policy
Specialty Pharmacy Must use Accredo or network pharmacy Cigna member portal

Prior Authorization Process

Who submits the PA? Your prescribing physician or their staff must submit the prior authorization request to Cigna.

How to submit:

  1. Electronic submission (fastest): Use CoverMyMeds or Surescripts
  2. Phone: Call Cigna at 1-800-882-4462
  3. Fax: Submit completed PA forms (verify current fax number with Cigna)

Step-by-Step: Fastest Path to Approval

  1. Verify coverage - Check your Cigna formulary and confirm Skyrizi is covered
  2. Gather documentation - Collect PASI scores, prior treatment history, lab results, TB screening
  3. Submit PA electronically - Use CoverMyMeds for 1-2 day processing vs. 5+ days for paper
  4. Include step therapy documentation - Show TNF inhibitor trial and failure/intolerance
  5. Follow up in 3 business days - Check status via provider portal or phone
  6. If denied, appeal immediately - Don't wait; start internal appeal within 180 days
  7. Consider peer-to-peer - Request physician-to-physician review if initially denied

Timing and Deadlines

How long does PA take? Cigna aims for 1-5 business days after receiving complete documentation. Electronic submissions process faster than paper.

What if it's urgent? Request expedited review if delay could harm your health. Cigna must respond within 24-72 hours for urgent requests.

Key Michigan Deadlines

  • Internal appeal: 180 days from denial notice
  • External review with DIFS: 127 days from final internal denial
  • DIFS standard review: 60 days maximum
  • DIFS expedited review: 72 hours for urgent cases

Medical Necessity Criteria

Your doctor must document specific criteria depending on your condition:

For Plaque Psoriasis

  • Disease severity: PASI ≥12 or BSA ≥10%
  • Step therapy: Trial and failure of at least one TNF inhibitor
  • Quality of life impact: Documentation of functional impairment
  • TB screening: Required before starting treatment

For Psoriatic Arthritis

  • Active disease: Joint counts, HAQ-DI scores
  • Prior treatments: Failure of ≥2 systemic therapies for ≥3 months
  • Functional assessment: Impact on daily activities
  • Specialist evaluation: Rheumatologist or dermatologist assessment

For Crohn's Disease

  • Disease activity: CDAI >220, CRP elevation, endoscopic findings
  • Treatment failures: ≥1 conventional therapy AND ≥1 TNF inhibitor
  • Gastroenterologist prescriber: Required for IBD indications
  • Age requirement: Patient must be ≥18 years old
Clinician Corner: Include specific PASI scores with dates, document exact TNF inhibitors tried with start/stop dates and reasons for discontinuation. Reference FDA labeling and AAD guidelines for psoriasis severity thresholds.

Cost and Specialty Pharmacy

What will I pay? As a specialty tier drug, you'll typically pay coinsurance (20-33% of drug cost) rather than a fixed copay. Exact amounts depend on your specific Cigna plan.

Where to fill? Cigna requires specialty medications like Skyrizi to be filled through Accredo or another network specialty pharmacy. Your prescription will automatically be transferred.

Savings options:

Denials and Appeals

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Step therapy not met Document TNF inhibitor trial with dates, doses, and reason for failure
Not medically necessary Submit PASI scores ≥12, photos, quality of life assessments
Experimental/investigational Reference FDA approval and clinical guidelines
Quantity limit exceeded Specialist letter explaining dosing rationale
Non-formulary Submit formulary exception with comparative effectiveness data

Internal Appeal Process

  1. File within 180 days of denial notice
  2. Submit supporting documentation: Medical records, lab results, specialist letters
  3. Request peer-to-peer review: Ask for physician-to-physician discussion
  4. Get decision within 30 days for standard appeals, 72 hours for expedited

Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals by analyzing the denial basis and drafting point-by-point rebuttals aligned to the plan's own rules.

Reauthorization Requirements

When to reauthorize? Typically annually, but check your specific approval letter for the exact date.

What's needed for renewal?

  • Updated disease activity scores (PASI, CDAI, joint counts)
  • Documentation of treatment response and tolerability
  • Continued medical necessity attestation from prescriber
  • Updated lab monitoring results

Troubleshooting Common Issues

PA portal down? Call Cigna provider services at 1-800-882-4462 or submit by fax as backup.

Missing forms? Download current PA forms from Cigna's provider portal.

Prescription transferred without notice? This is normal for specialty drugs. Accredo will contact you to coordinate delivery.

Quantity limit blocking refill? Your doctor can request a quantity limit override with clinical justification.

Michigan External Review Process

If Cigna denies your internal appeal, you have strong rights under Michigan law:

How Michigan's External Review Works

  1. File within 127 days of Cigna's final denial
  2. Submit to Michigan DIFS using their external review request form
  3. Independent medical review by experts in your condition
  4. Binding decision - if approved, Cigna must cover the treatment

Contact Michigan DIFS: 877-999-6442 for assistance with external review process.

Expedited review available: 72-hour decision if delay would jeopardize your health (requires physician letter).

From our advocates: We've seen many Skyrizi denials overturned on external review in Michigan when patients included comprehensive PASI documentation and detailed TNF inhibitor failure histories. The key is submitting all available clinical evidence, not just the minimum requirements.

FAQ

Q: How long does Cigna PA take for Skyrizi in Michigan? A: 1-5 business days for electronic submissions, up to 14 days for paper submissions. Expedited reviews take 24-72 hours.

Q: What if Skyrizi is non-formulary on my plan? A: Request a formulary exception with your doctor's support, documenting medical necessity and why preferred alternatives aren't suitable.

Q: Can I request expedited appeal if my psoriasis is severe? A: Yes, if your doctor confirms that delay would worsen your condition or cause serious harm. Submit a physician letter with your expedited appeal request.

Q: Does step therapy apply if I tried TNF inhibitors in another state? A: Yes, step therapy requirements follow the patient, not the location. Document your prior TNF inhibitor trials regardless of where they occurred.

Q: What happens if I miss the 127-day external review deadline? A: You lose the right to external review for that specific denial. Always file appeals promptly and track all deadlines carefully.

Q: Can Counterforce Health help with my Cigna denial? A: Yes, Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and drafting evidence-backed responses tailored to each payer's specific requirements.

Sources & Further Reading

This guide provides educational information and is not medical advice. Always consult your healthcare provider about treatment decisions. For official appeals assistance in Michigan, contact DIFS at 877-999-6442 or visit michigan.gov/difs.

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