Does Humana cover Skyrizi in Michigan?

Humana covers Skyrizi (risankizumab) in Michigan but requires prior authorization and typically requires documented failure of first-line TNF inhibitor therapies like Humira before approval.

How long does Humana prior authorization take for Skyrizi?

Humana typically processes prior authorization requests for Skyrizi within 3-5 business days for standard requests. Urgent requests may be processed within 24-72 hours.

What are the step therapy requirements for Skyrizi with Humana?

Humana typically requires documented failure or contraindication to TNF inhibitors (like Humira, Enbrel, or Remicade) before approving Skyrizi as a second-line biologic therapy.

Can I appeal a Humana denial for Skyrizi coverage?

Yes, you can appeal a Humana denial for Skyrizi. You typically have 180 days from the denial date to file an appeal with additional medical documentation supporting medical necessity.

By Counterforce Health Team in Skyrizi (risankizumab) — 20 Oct 2025

Getting Skyrizi (Risankizumab) Covered by Humana in Michigan: Prior Authorization, Appeals, and Formulary Alternatives

Quick Answer: Getting Skyrizi Covered by Humana in Michigan

Fastest path to approval: Skyrizi (risankizumab) requires prior authorization from Humana and typically isn't covered as a first-line therapy. You'll need documented failure of TNF inhibitors like Humira first. First step today: Have your prescriber gather records of previous biologic trials and submit a prior authorization request through Humana's provider portal. If denied, you have 65 days to appeal and can request Michigan's external review within 127 days of final denial through Michigan DIFS.

When Formulary Alternatives Make Sense
Typical Alternatives by Drug Class
Pros and Cons Overview
Exception Strategy for Skyrizi
Switching Logistics
Re-trying for Skyrizi Later
Appeals Playbook for Michigan
Common Denial Reasons & Fixes
Cost-Saving Options
FAQ

When Formulary Alternatives Make Sense

Humana's 2024-2025 formularies do not include Skyrizi as a covered drug, with specific alternatives listed including Stelara, Tremfya, Simponi, Taltz, and Xeljanz. Before pursuing a formulary exception, it's worth understanding when these alternatives might work for your condition.

Clinical Appropriateness: If you haven't tried TNF inhibitors or IL-12/23 blockers, starting with a covered alternative often makes medical and financial sense. Many patients achieve excellent results with first-line options like Humira (covered on Tier 5) or Stelara (listed as a covered alternative).

Contraindications Matter: Alternatives become less viable if you have specific contraindications—active tuberculosis history might rule out certain TNF inhibitors, or hepatitis B could limit your options to IL-23 blockers like Tremfya.

Disease Complexity: Patients with multiple conditions (psoriasis + psoriatic arthritis + IBD) need drugs approved for all relevant indications. Stelara covers all four Skyrizi indications, while Tremfya only treats psoriasis and psoriatic arthritis.

Typical Alternatives by Drug Class

Covered IL-12/23 and IL-23 Inhibitors

Stelara (ustekinumab) - Listed as a covered alternative for all Skyrizi indications (psoriasis, psoriatic arthritis, Crohn's disease, ulcerative colitis). Administered as subcutaneous injections every 12 weeks after loading doses.

Tremfya (guselkumab) - Another IL-23 inhibitor that's covered for psoriasis and psoriatic arthritis. Not FDA-approved for IBD conditions as of 2024.

TNF Inhibitors (Step Therapy Requirements)

Humira (adalimumab) - Covered on Tier 5 specialty with biosimilars Cyltezo and Hyrimoz also available. Often required as first-line therapy before IL-23 inhibitors.

Simponi (golimumab) - Covered alternative for psoriatic arthritis and ulcerative colitis.

JAK Inhibitors

Rinvoq (upadacitinib) - Covered on Tier 5 for psoriatic arthritis, Crohn's disease, and ulcerative colitis (not psoriasis).

Xeljanz (tofacitinib) - Listed as a covered alternative for psoriatic arthritis and ulcerative colitis.

Pros and Cons Overview

Alternative	Pros	Cons	Access Notes
Stelara	All 4 indications; established safety profile	Less frequent dosing may affect some patients	Prior authorization required
Tremfya	Similar mechanism to Skyrizi	Limited to psoriasis/PsA only	May require step therapy
Humira	Extensive real-world data; biosimilars available	Injection frequency (every other week)	Often required first-line
Rinvoq	Oral administration	Black box warnings; monitoring requirements	Prior authorization needed

Exception Strategy for Skyrizi

Medical Necessity Documentation

When covered alternatives aren't appropriate, your prescriber needs to submit a comprehensive formulary exception request with specific documentation:

Clinical History: Detailed records of previous biologic trials, including drug names, dosages, treatment duration, and specific reasons for discontinuation (lack of efficacy vs. adverse effects).

Contraindications: Clear documentation of why formulary alternatives are contraindicated—drug interactions, comorbidities, or previous serious adverse reactions.

Treatment Goals: Specific, measurable outcomes expected with Skyrizi that couldn't be achieved with alternatives.

Supporting Evidence

Include relevant clinical guidelines and FDA labeling that support Skyrizi's use for your specific condition and severity. For complex cases involving multiple autoimmune conditions, coordination letters from specialists can strengthen the request.

Tip: Counterforce Health specializes in turning insurance denials into targeted appeals by analyzing denial letters and crafting evidence-backed rebuttals aligned to each plan's specific rules and formulary requirements.

Switching Logistics

Provider Coordination

Specialty Alignment: Ensure your dermatologist, rheumatologist, and/or gastroenterologist coordinate the switch. Different specialists may have varying preferences based on their experience with specific biologics.

Washout Considerations: Most biologic switches don't require washout periods, but your provider will consider the previous drug's half-life and your disease activity level.

Pharmacy Coordination

Specialty Pharmacy Networks: Humana contracts with specific specialty pharmacies. Verify your new biologic is available through your assigned pharmacy before switching.

Prior Authorization Transfer: Each new biologic requires its own prior authorization—approvals don't transfer between drugs, even within the same class.

Re-trying for Skyrizi Later

Documentation During Alternative Trials

Response Tracking: Maintain detailed records of symptom scores (PASI for psoriasis, joint counts for psoriatic arthritis, clinical indices for IBD) during alternative therapy trials.

Adverse Effect Documentation: Record any side effects, lab abnormalities, or tolerability issues with covered alternatives. This strengthens future Skyrizi requests.

Treatment Duration: Ensure adequate trial periods—typically 3-6 months for biologics—to demonstrate definitive failure or intolerance.

Resubmission Strategy

After documenting inadequate response or intolerance to covered alternatives, resubmit the Skyrizi request with updated clinical evidence. Include comparative effectiveness data showing why Skyrizi's specific mechanism (IL-23 p19 subunit inhibition) is more appropriate than alternatives.

Appeals Playbook for Michigan

Humana Internal Appeals

Timeline: 65 calendar days from denial notice to file appeal (updated January 2025).

Submission: Call 866-274-9834 or mail to: Humana Gold Plus SNP-DE in Michigan
P.O. Box 14163
Lexington, KY 40512-4163
Attn: Grievance & Appeals Department

Decision Timeline: Humana must respond within 7 calendar days for standard appeals, 72 hours for expedited appeals.

Michigan External Review

Eligibility: After Humana's final internal denial, you have 127 days to request external review through Michigan DIFS.

Process: Submit request via DIFS online form or call 877-999-6442. Independent medical experts review whether the denial was appropriate.

Timeline: Standard external reviews decided within 60 days; expedited reviews within 72 hours for urgent cases.

Required Documentation

Original denial letter from Humana
All medical records supporting medical necessity
Prescriber's letter detailing why Skyrizi is specifically needed
Documentation of alternative therapy trials and outcomes

Common Denial Reasons & Fixes

Denial Reason	How to Overturn	Required Documentation
Step therapy not completed	Demonstrate TNF inhibitor failure	Treatment records, response measurements
Not medically necessary	Provide condition severity evidence	PASI scores, imaging, lab results
Non-formulary status	Request formulary exception	Prescriber medical necessity letter
Quantity/frequency limits	Show standard dosing is inadequate	Clinical response data, guidelines

Cost-Saving Options

AbbVie Complete: Manufacturer support program offering copay assistance and patient services. Eligible patients may pay as little as $5 per month.

Foundation Grants: Organizations like the Patient Advocate Foundation and HealthWell Foundation provide grants for specialty medications.

Michigan Programs: Check eligibility for state pharmaceutical assistance programs through Michigan DIFS.

When working with Counterforce Health, these cost-saving options are integrated into the appeal strategy to demonstrate that coverage, rather than cost-sharing assistance, is the appropriate solution.

FAQ

How long does Humana prior authorization take in Michigan?
Standard requests: 72 hours; expedited: 24 hours after receiving complete documentation.

What if Skyrizi is completely non-formulary?
Request a formulary exception with prescriber documentation that covered alternatives are inappropriate or ineffective.

Can I request expedited appeal if my condition is worsening?
Yes, if delay would jeopardize your health. Your prescriber must provide supporting documentation of urgency.

Does step therapy apply if I failed TNF inhibitors in another state?
Medical records from any state showing adequate trials and failures should satisfy step therapy requirements.

What's the success rate for Skyrizi appeals with Humana?
Humana's overall Medicare Advantage denial rate is approximately 3.5% (2023), with many denials overturned when proper documentation is provided.

How do I track my appeal status?
Use Humana's online member portal or call the number on your member ID card for status updates.

From our advocates: We've seen cases where patients initially denied Skyrizi received approval after documenting specific adverse effects to Stelara (like injection site reactions) combined with incomplete psoriasis clearance. The key was quantifying the treatment gap—showing PASI scores remained above target despite adequate trial duration. This demonstrates why a different IL-23 mechanism was medically necessary.

Disclaimer: This information is for educational purposes only and doesn't constitute medical or legal advice. Coverage decisions depend on individual medical circumstances and specific plan terms. Always consult with your healthcare provider and review your plan documents.

Need Help? Contact Michigan DIFS at 877-999-6442 for insurance questions or visit michigan.gov/difs for external review forms.

Sources & Further Reading

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