By Counterforce Health Team in Skyrizi (risankizumab) —

Getting Skyrizi (Risankizumab) Covered by Humana in Texas: Complete Guide to Prior Authorization and Appeals

Answer Box: Quick Path to Approval

Skyrizi (risankizumab) requires prior authorization from Humana in Texas. Most denials stem from missing step therapy documentation or insufficient disease severity proof. Your fastest path: (1) Have your dermatologist complete Humana's Medicare PA form with PASI scores and failed TNF inhibitor records, (2) Submit via Humana's provider portal with TB screening and liver function tests, (3) If denied, request a peer-to-peer review within 65 days. Standard approval takes 14-30 days; expedited review available if delay risks serious harm.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Timing and Urgency
  4. Required Documentation
  5. Cost Considerations
  6. Denials and Appeals in Texas
  7. Renewal Requirements
  8. Specialty Pharmacy Network
  9. Troubleshooting Common Issues
  10. Frequently Asked Questions

Coverage Basics

Is Skyrizi Covered by Humana?

Skyrizi (risankizumab) is covered on Humana's 2025 Medicare formularies as a Tier 5 specialty drug, but requires prior authorization (PA) for all indications including plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis. The drug is not explicitly listed in some Humana Basic Rx Plan formularies, requiring formulary exception requests in certain cases.

Which Humana Plans Apply?

This guide covers:

  • Humana Medicare Advantage (Part C) plans
  • Humana Medicare Part D prescription drug plans
  • Humana dual-eligible special needs plans (D-SNPs)
Note: Self-funded employer plans follow different rules and may have varying PA criteria.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Must be approved before dispensing Humana PA Lists
Step Therapy Try preferred drugs first PA form criteria section
Specialty Pharmacy Must use designated network pharmacy CenterWell Specialty
Medical Necessity Clinical justification required Provider medical necessity letter
Quantity Limits May restrict quantity per fill Plan-specific formulary

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient or staff)
    • Check Humana's drug list tool for your specific plan
    • Confirm Skyrizi's tier and PA requirements
    • Timeline: 5-10 minutes
  2. Gather Required Documentation (Clinic staff)
    • Complete medical records with PASI scores
    • Lab results (TB screening, liver function tests)
    • Prior therapy failure documentation
    • Timeline: 1-2 days
  3. Complete PA Form (Provider)
  4. Submit Request (Provider)
  5. Track Status (Patient and provider)
    • Monitor via provider portal or member services
    • Follow up if no response in 14 days
    • Timeline: Ongoing
  6. Handle Decision (Patient and provider)
    • If approved: Fill at specialty pharmacy
    • If denied: Request peer-to-peer or appeal
    • Timeline: Same day as decision
  7. Fill Prescription (Patient)
    • Use CenterWell Specialty Pharmacy or approved network
    • Coordinate delivery and injection training
    • Timeline: 3-7 days

Timing and Urgency

Standard Timelines

  • PA Decision: 14-30 days from complete submission
  • Expedited Review: 72 hours with physician-supported urgency
  • Appeal Deadline: 65 days from denial notice
  • Renewal Submission: Start 60-90 days before expiration

When to Request Expedited Review

Request expedited processing if standard timing could:

  • Seriously jeopardize your health
  • Risk hospitalization or emergency care
  • Cause irreversible disease progression

How to request: Call the number on your denial letter and state: "I am requesting an expedited appeal because delay may seriously jeopardize my health."

Required Documentation

Medical Necessity Letter Checklist

Your dermatologist or prescribing physician should include:

Patient Information:

  • Full name, date of birth, Humana ID number
  • Diagnosis with ICD-10 codes
  • Disease duration and severity

Disease Severity Documentation:

  • PASI score ≥10 and/or body surface area ≥10%
  • High-impact locations (hands, feet, face, genitals)
  • Functional impairment or quality of life impact (DLQI if available)
  • Photos of affected areas (optional but helpful)

Treatment History:

  • All prior psoriasis therapies with dates
  • Reason for discontinuation (inadequate response, adverse effects, contraindications)
  • Specific documentation of TNF inhibitor failure or intolerance
  • Response to each therapy (e.g., "PASI 50 after 16 weeks adalimumab")

Clinical Rationale:

  • Why Skyrizi is medically necessary
  • Risks of not using Skyrizi or forcing alternatives
  • Expected treatment goals and monitoring plan

Required Lab Tests and Screening

Tuberculosis Screening:

  • QuantiFERON-TB Gold or tuberculin skin test (TST)
  • Chest X-ray if clinically indicated
  • Documentation of any prior latent TB treatment

Liver Function Tests:

  • ALT, AST, bilirubin at baseline
  • For renewals: updated LFTs showing stability

Additional Labs (as clinically appropriate):

  • Complete blood count (CBC)
  • Comprehensive metabolic panel (CMP)
  • Hepatitis B and C screening if risk factors present
Tip: Include all lab results with dates in your PA submission to avoid delays from missing documentation requests.

Cost Considerations

Understanding Your Costs

As a Tier 5 specialty drug, Skyrizi typically requires:

  • Specialty pharmacy dispensing
  • Higher copay or coinsurance than standard medications
  • Possible coverage gap (donut hole) implications for Medicare Part D

Cost-Saving Options

AbbVie Patient Support:

  • Complete Savings Program for eligible patients
  • May reduce copays to as low as $5 per dose
  • Income and insurance requirements apply

Foundation Assistance:

  • Patient Advocate Foundation
  • Good Days Foundation
  • HealthWell Foundation

Contact these organizations directly to verify current programs and eligibility.

Denials and Appeals in Texas

Common Denial Reasons and Solutions

Denial Reason How to Overturn
Insufficient disease severity Submit updated PASI scores, photos, DLQI
Missing step therapy Document TNF inhibitor failure with dates and reasons
Inadequate medical necessity Strengthen physician letter with guidelines and functional impact
Missing labs Submit TB screening and liver function tests
Non-formulary status Request formulary exception with medical justification

Texas Appeals Process

Internal Appeal (Level 1):

  • Deadline: 65 days from denial notice
  • Timeline: 30 days for pre-service, 60 days for post-service decisions
  • How to file: Use Humana appeals process or written request

External Review (Level 2):

  • When available: After internal appeal denial for medical necessity
  • Timeline: 20 days standard, 5 days for urgent cases
  • Authority: Texas Department of Insurance contracted Independent Review Organization
  • Cost: Free to patient; insurer pays IRO fees

Peer-to-Peer Review: Before or during appeals, request a peer-to-peer discussion between your physician and a Humana medical director. Call the provider number on your denial letter to schedule.

Texas-Specific Resources

  • Texas Department of Insurance: 1-800-252-3439
  • Office of Public Insurance Counsel: 1-877-611-6742
  • IRO Information Line: 1-866-554-4926

For Medicaid denials, request a fair hearing through Texas Health and Human Services.

Renewal Requirements

When to Start Renewal

Begin your Skyrizi renewal process 60-90 days before your current authorization expires. Humana authorizations typically last 12 months.

Renewal Documentation

Updated Clinical Assessment:

  • Current PASI score and disease activity
  • Response to Skyrizi (improvement from baseline)
  • Any flares when doses delayed or missed

Safety Monitoring:

  • Updated liver function tests
  • TB screening if clinically indicated (new risk factors)
  • Documentation of no serious infections or contraindications

Adherence Documentation:

  • Pharmacy fill history
  • Provider attestation of patient compliance
  • Any access or adherence challenges
From our advocates: "We've seen successful renewals include specific PASI improvement data, like 'PASI reduced from 18 to 4 on Skyrizi, with flares to PASI 12 when delayed due to insurance gaps.' This objective data helps demonstrate ongoing medical necessity."

Specialty Pharmacy Network

Why Specialty Pharmacy is Required

Skyrizi requires special handling due to:

  • Cold storage requirements
  • Patient education and injection training
  • Clinical monitoring and support
  • Coordination with prescribing physicians

Humana's Preferred Specialty Pharmacy

CenterWell Specialty Pharmacy (Humana-affiliated):

  • Integrated with Humana's systems
  • Streamlined PA processing
  • Clinical support and injection training
  • Coordination with prescribing physicians

What to Expect

  1. Transfer Process: Your prescription may be automatically transferred to specialty pharmacy
  2. Clinical Intake: Pharmacist will review your medical history and current medications
  3. Delivery Coordination: Scheduled delivery with temperature monitoring
  4. Injection Training: Video or phone support for self-administration
  5. Ongoing Support: Refill reminders and clinical monitoring

Troubleshooting Common Issues

PA Form Problems

Portal Access Issues:

  • Contact Humana Provider Services for login assistance
  • Verify current portal URL and system requirements
  • Use fax backup: Submit to Medication Intake Team (number on PA form)

Missing Information Requests:

  • Respond within requested timeframe (usually 14 days)
  • Submit via same method as original request
  • Include reference number from original submission

Prescription Transfer Issues

Unexpected Specialty Pharmacy Transfer:

  • Contact your prescribing physician to verify authorization
  • Confirm with CenterWell that they have complete clinical information
  • Verify insurance coverage before first fill

Delivery Problems:

  • Coordinate with specialty pharmacy for appropriate delivery times
  • Ensure someone is available to receive temperature-sensitive medication
  • Have backup refrigeration plan ready

Frequently Asked Questions

How long does Humana PA take for Skyrizi in Texas? Standard processing takes 14-30 days from complete submission. Expedited review is available within 72 hours if delay could seriously jeopardize your health.

What if Skyrizi is non-formulary on my Humana plan? Request a formulary exception with medical justification. You may receive a temporary 30-day supply while the exception is reviewed.

Can I request an expedited appeal in Texas? Yes, both internal appeals and external reviews can be expedited if standard timing would jeopardize your health. Contact Humana immediately to request expedited processing.

Does step therapy apply if I failed TNF inhibitors outside Texas? Yes, prior therapy failures from any location count toward step therapy requirements. Ensure your physician includes complete treatment history with dates and outcomes.

What happens if I move between Humana plans in Texas? Your PA may need to be resubmitted if plan formularies differ. Contact your new plan within 30 days of enrollment to avoid coverage gaps.

How do I check my Skyrizi PA status? Providers can check via Humana's provider portal. Patients can call member services using the number on their insurance card.

What if my doctor leaves the Humana network? You may continue current treatment for up to 90 days while transitioning to a new in-network provider. Contact Humana to coordinate continuity of care.

Can I appeal to an external reviewer in Texas? Yes, Texas law provides independent external review for medical necessity denials through Independent Review Organizations contracted by the Texas Department of Insurance.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating targeted, evidence-backed responses. Our platform analyzes denial letters and plan policies to identify specific coverage criteria, then drafts point-by-point rebuttals with the right clinical evidence and procedural requirements. For complex cases like Skyrizi approvals, Counterforce Health can help ensure your appeal includes all necessary documentation to meet Humana's specific requirements and maximize approval chances.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms, medical circumstances, and current policies. Always consult with your healthcare provider about treatment decisions and contact Humana directly for the most current coverage information. For additional assistance with insurance appeals in Texas, contact the Texas Department of Insurance at 1-800-252-3439.

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