By Counterforce Health Team in Skyrizi (risankizumab) —

Getting Skyrizi (Risankizumab) Covered by UnitedHealthcare in Washington: A Complete Approval Guide

Answer Box: Your Fastest Path to Skyrizi Coverage

Getting Skyrizi (risankizumab) covered by UnitedHealthcare in Washington requires prior authorization. Most approvals succeed when you document moderate-to-severe disease and show failure of at least one conventional therapy or targeted biologic. Start today by: (1) calling UnitedHealthcare member services to confirm your PA requirements, (2) gathering records of prior treatments, and (3) having your dermatologist submit a complete PA request through the UnitedHealthcare provider portal. If denied, Washington's external review process through certified Independent Review Organizations gives you strong appeal rights within 180 days.

Table of Contents

Understanding UnitedHealthcare's Skyrizi Requirements

UnitedHealthcare requires prior authorization for Skyrizi (risankizumab) across all indications through their OptumRx pharmacy benefit manager. The 2025 criteria vary by plan type but follow consistent patterns for moderate-to-severe plaque psoriasis, psoriatic arthritis, and inflammatory bowel disease.

For plaque psoriasis, UnitedHealthcare's medical necessity policy requires documentation of moderate-to-severe disease plus failure of at least one conventional systemic therapy (methotrexate, cyclosporine, PUVA, or acitretin) OR prior treatment with any targeted immunomodulator like TNF inhibitors or other biologics.

Washington residents benefit from strong consumer protections. If UnitedHealthcare denies your request, you can pursue internal appeals followed by external review through Washington's certified Independent Review Organizations under RCW 48.43.535. The state's Office of the Insurance Commissioner actively supports consumers through this process.

Tip: UnitedHealthcare has two policy versions for Skyrizi - a stricter "medical necessity" version requiring step therapy, and a simpler "PA/Notification" version with fewer requirements. Your specific plan determines which applies.

Step-by-Step: Fastest Path to Approval

1. Verify Your Benefits (Patient + Clinic)

Call UnitedHealthcare member services using the number on your insurance card. Ask specifically about:

  • Prior authorization requirements for Skyrizi
  • Your plan's formulary tier placement
  • Step therapy requirements
  • Copay maximizer/accumulator programs

Timeline: 10-15 minutes
Submit via: Phone call to member services

2. Gather Documentation (Clinic Staff)

Collect comprehensive records showing:

  • Diagnosis with ICD-10 codes (L40.0 for plaque psoriasis)
  • Disease severity documentation (BSA involvement, PASI scores if available)
  • Complete list of prior therapies with dates, dosing, duration, and outcomes
  • Current medications and contraindications
  • Recent lab work (TB screening, hepatitis panel, CBC)

Timeline: 1-2 business days
Required for: PA submission

3. Submit Prior Authorization (Prescriber)

Your dermatologist submits the PA request through:

  • UnitedHealthcare Provider Portal (preferred)
  • OptumRx CoverMyMeds platform
  • Fax to the number listed on your denial letter

Timeline: 5-15 business days for determination
Submit via: UnitedHealthcare Provider Portal (verify current link)

4. Monitor and Follow Up (Patient + Clinic)

Track your request status through:

  • UnitedHealthcare member portal
  • Provider portal TrackIt system
  • Phone follow-up after 10 business days

Timeline: Check status weekly
Escalate if: No response after 15 business days

5. If Denied: Request Peer-to-Peer Review (Prescriber)

Before formal appeals, request a peer-to-peer discussion between your dermatologist and a UnitedHealthcare medical director within 24 hours of denial.

Timeline: 3 business days (inpatient) or 21 days (outpatient)
Submit via: UnitedHealthcare Provider Portal scheduling request

6. File Internal Appeal (Patient or Prescriber)

Submit reconsideration request with additional clinical documentation, guidelines citations, and detailed medical necessity rationale.

Timeline: 30 days for pre-service appeals
Submit via: Provider portal or member portal

7. External Review if Needed (Patient)

Request Independent Review Organization review through UnitedHealthcare if internal appeals are unsuccessful.

Timeline: 180 days from final internal denial to request
Authority: Washington RCW 48.43.535

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all indications Member benefits summary UHC Provider Portal
Step Therapy One conventional or targeted therapy failure PA policy documents UHC Skyrizi Policy
Prescriber Requirement Dermatologist or consultation Medical necessity criteria UHC Policy PDF
Appeals Deadline 180 days for external review Washington state law RCW 48.43.535
Formulary Tier Varies by plan Plan documents Verify with member services

When UnitedHealthcare Says No: Appeals in Washington

Washington state provides robust appeal rights that often succeed with proper documentation. The process follows a clear timeline with strict insurer obligations.

Internal Appeals Process

Step 1: Reconsideration Request

  • Must be filed first for post-service denials
  • 30-day response timeline for pre-service requests
  • Submit through provider or member portal with tracking number

Step 2: Second-Level Appeal

  • Available if reconsideration is denied
  • Additional clinical evidence and peer-reviewed citations
  • 30-day response timeline

External Review Rights

After completing internal appeals, Washington residents can request external review by certified Independent Review Organizations. This process is free to patients and binding on UnitedHealthcare.

Key Timeline Requirements:

  • UnitedHealthcare must assign IRO within 3 business days
  • You get at least 5 business days to submit additional evidence
  • Standard review: decision within 45 days
  • Expedited review: decision within 72 hours if health is at risk

How to Request: Contact UnitedHealthcare directly and state: "I am requesting an external review by an Independent Review Organization under Washington law RCW 48.43.535."

Important: The external review decision is binding on UnitedHealthcare. If the IRO overturns the denial, your insurer must provide coverage.

For assistance with the appeals process, contact the Washington Office of the Insurance Commissioner Consumer Advocacy line at 1-800-562-6900.

Cost Assistance and Patient Support Programs

Multiple programs can reduce or eliminate your Skyrizi costs, even during UnitedHealthcare coverage gaps.

AbbVie Manufacturer Programs

Skyrizi Complete Savings Card

  • Reduces costs to as low as $0 per quarterly dose
  • Annual maximum benefit: $14,000 per calendar year
  • Available for eligible commercial insurance patients
  • Enroll: Call 1-866-SKYRIZI (1-866-759-7494)

Bridge Support During Denials

  • Free Skyrizi for up to 2 years during coverage appeals
  • Requires appeal documentation every 180 days
  • Available through Skyrizi Complete program

myAbbVie Assist Patient Assistance Program

  • Free Skyrizi for uninsured, underinsured, Medicare, and Medicaid patients
  • Income-based eligibility requirements
  • Phone support: 1-800-222-6885

Federal and State Options

Medicare Extra Help (Low-Income Subsidy)

  • Reduces premiums, deductibles, and copays for Part D drugs
  • Apply through Social Security or Washington Medicaid offices
  • Required before myAbbVie Assist for income under 150% FPL

Washington Apple Health (Medicaid)

  • May cover Skyrizi subject to state formulary and PA requirements
  • Exception to Rule process available for non-formulary drugs
  • Contact local Apple Health offices for eligibility screening

Counterforce Health helps patients navigate these complex coverage decisions by turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to identify the specific denial basis and draft point-by-point rebuttals aligned to each plan's own rules.

Common Denial Reasons and How to Fix Them

Denial Reason How to Overturn Required Documentation
Insufficient disease severity Document BSA ≥3% or sensitive area involvement PASI scores, photos, clinical notes
Missing step therapy Show prior conventional or biologic failure Pharmacy records, treatment timelines
Lack of specialist prescribing Dermatologist prescription or consultation Referral documentation, specialist notes
Inadequate prior authorization Complete PA with all required elements Medical necessity letter, lab results
Experimental/investigational Cite FDA approval and clinical guidelines FDA label, society recommendations

Clinician Corner: Medical Necessity Documentation

Medical Necessity Letter Checklist:

✓ Patient Demographics: Age, diagnosis with ICD-10 codes
✓ Disease Severity: BSA involvement, PASI scores, impact on quality of life
✓ Prior Treatments: Specific drugs, dates, duration, outcomes, reasons for discontinuation
✓ Clinical Rationale: Why Skyrizi is appropriate based on mechanism of action
✓ Guideline Support: Reference FDA labeling and dermatology society recommendations
✓ Monitoring Plan: Lab surveillance, follow-up schedule, response assessment

Key Clinical Guidelines:

Documentation Tips:

  • Include specific PASI scores or BSA percentages when available
  • Document functional impairment (work, sleep, social activities)
  • List contraindications to formulary alternatives
  • Provide timeline of prior therapy failures with objective measures

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Washington? Standard PA decisions are made within 15 business days. Expedited reviews for urgent cases are completed within 72 hours.

What if Skyrizi is non-formulary on my UnitedHealthcare plan? Non-formulary drugs can still be covered through medical necessity exceptions. Your prescriber must document why formulary alternatives are inappropriate.

Can I request an expedited appeal in Washington? Yes, if waiting for standard review would seriously jeopardize your health. Expedited external reviews must be decided within 72 hours.

Does step therapy apply if I failed treatments outside Washington? Yes, prior treatment history from any state counts toward step therapy requirements. Provide complete pharmacy records and treatment documentation.

What happens if I disagree with the external review decision? External review decisions are binding on UnitedHealthcare. If unfavorable, you may still contact the Washington Office of the Insurance Commissioner for additional guidance.

How do copay maximizer programs affect my Skyrizi costs? If your UnitedHealthcare plan uses copay maximizers, AbbVie's assistance may be limited to $4,000 annually instead of the full $14,000 benefit.

Can my dermatologist prescribe Skyrizi for off-label uses? UnitedHealthcare typically covers FDA-approved indications. Off-label uses require stronger medical necessity documentation and may face higher denial rates.

What should I do if UnitedHealthcare doesn't respond to my appeal? Contact the Washington Office of the Insurance Commissioner at 1-800-562-6900 to report non-compliance with state appeal timelines.

Sources & Further Reading

This article is for informational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For assistance with insurance appeals and coverage decisions, Counterforce Health provides specialized support in turning denials into successful approvals through evidence-based appeal strategies.

Disclaimer: Insurance coverage policies change frequently. Verify all requirements, forms, and deadlines with UnitedHealthcare and the Washington Office of the Insurance Commissioner before taking action. This information was current as of January 2025.

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