By Counterforce Health Team in Skyrizi (risankizumab) —

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

Answer Box: Getting Skyrizi Covered by Aetna (CVS Health) in Florida

Yes, Skyrizi (risankizumab) is covered by most Aetna (CVS Health) plans in Florida as a specialty medication requiring prior authorization. To get approved:

  1. Submit PA form with documented moderate-to-severe psoriasis (≥10% BSA or PASI ≥10) and failure/intolerance to at least one TNF inhibitor
  2. Include TB screening (completed within 12 months) and hepatitis B tests
  3. Use CVS Specialty Pharmacy for dispensing after approval

Standard decisions take 30-45 days; expedited reviews resolve within 72 hours. If denied, you have 180 days to appeal internally, then can request external review through Florida's Department of Financial Services.

Table of Contents

Coverage Basics

Is Skyrizi Covered by Aetna (CVS Health)?

Skyrizi is covered by most Aetna commercial plans, Medicare Advantage, and Florida Medicaid managed care as a specialty tier medication. All plans require prior authorization before dispensing. The drug must be obtained through CVS Specialty Pharmacy or other approved specialty pharmacy networks.

Which Plans Cover Skyrizi?

  • Commercial/Employer Plans: Covered with PA and specialty pharmacy requirement
  • Medicare Advantage: Covered with PA; copay assistance not available
  • Florida Medicaid: Covered through Aetna Better Health Florida with PA
  • Individual/ACA Plans: Coverage varies by formulary tier
Note: Government insurance beneficiaries (Medicare, Medicaid, TRICARE, VA) cannot use manufacturer copay assistance programs.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • Insurance card and member ID
    • Complete medical records showing psoriasis severity
    • Documentation of prior therapy failures
    • Recent TB and hepatitis B screening results
  2. Complete PA Form (Prescriber)
  3. Submit to Aetna (Prescriber/Staff)
    • Fax: 1-888-267-3277
    • Phone: 1-866-752-7021 (TTY: 711)
    • Online: Via Availity provider portal
  4. Track Status (Patient/Prescriber)
    • Check Availity portal or call member services
    • Standard review: 30-45 days
    • Expedited review: 72 hours (with clinical urgency)
  5. Coordinate with CVS Specialty (Patient)
    • Call 1-800-237-2767 after approval
    • Complete enrollment and delivery arrangements

Required Forms and Documentation

Document Who Completes Where to Find
Skyrizi Precertification Request Prescriber Aetna website
Medical records (diagnosis, severity, prior treatments) Prescriber Patient's medical chart
TB screening results Prescriber Lab/imaging reports
Hepatitis B panel Prescriber Lab reports

Medical Necessity Requirements

Psoriasis Severity Documentation

For moderate-to-severe plaque psoriasis approval, provide:

  • Body Surface Area (BSA) ≥10% affected, OR
  • PASI score ≥10, OR
  • Physician Global Assessment (PGA) ≥3
  • Duration ≥6 months of chronic plaque psoriasis
  • Failed conventional therapy (methotrexate, cyclosporine, acitretin) or phototherapy

Required Laboratory Screening

Tuberculosis Screening (within 12 months):

  • Tuberculin skin test (TST) or interferon-gamma release assay (IGRA)
  • Chest X-ray if TB risk factors present
  • Document negative results or completed treatment for latent TB

Hepatitis B Panel:

  • HBsAg (surface antigen)
  • Total anti-HBc (core antibody)
  • Anti-HBs (surface antibody)
Clinician Tip: Submit complete lab panels upfront. Incomplete screening is a common cause of PA delays or denials.

Step Therapy and Alternative Requirements

What Counts as Step Therapy for Aetna?

Required Prior Therapy Failure/Intolerance:

  • At least one TNF inhibitor (adalimumab/Humira, etanercept/Enbrel, infliximab/Remicade)
  • Document specific reasons for discontinuation:
    • Lack of efficacy after adequate trial (typically 12-16 weeks)
    • Intolerable side effects
    • Medical contraindications

Alternative Acceptable Failures:

  • Conventional systemic agents (methotrexate, cyclosporine, acitretin)
  • Phototherapy (PUVA, narrowband UVB)
  • Other IL-17 or IL-23 inhibitors

Documentation Requirements

For each prior therapy, include:

  • Drug name and dosing
  • Duration of treatment
  • Clinical response (PASI scores if available)
  • Reason for discontinuation
  • Date of last dose

Costs and Savings Options

Insurance Coverage and Copays

Skyrizi is typically placed on specialty tier with higher cost-sharing:

  • Copay: Often $100+ per fill for commercial plans
  • Coinsurance: 20-50% of negotiated price
  • Deductible: May apply before coverage begins

Manufacturer Savings Programs

Skyrizi Complete Savings Card:

  • Available for commercially insured patients
  • Can reduce copay to as low as $5 per dose
  • Not available for Medicare, Medicaid, TRICARE, or VA beneficiaries
  • Enroll at Skyrizi.com or call 1-866-SKYRIZI

Additional Support:

  • Skyrizi Complete Nurse Ambassador program
  • Insurance navigation assistance
  • Home injection training and support

Appeals Process in Florida

Internal Appeals Timeline

For Members (Non-Medicare):

  • Deadline: 180 days from denial notice
  • Decision: 30 days for pre-service, 60 days for post-service
  • Expedited: 72 hours for urgent medical needs

For Medicare Plans:

  • Deadline: 60 days from denial
  • Decision: 30 days standard, 72 hours expedited

How to File an Appeal

  1. Complete Appeal Form
  2. Submit Appeal
    • Online: Availity provider portal
    • Mail/Fax: Address specified on denial letter
    • Mark "EXPEDITED" if urgent medical situation
  3. Track Appeal Status
    • Monitor through provider portal
    • Call Aetna appeals line for updates

External Review in Florida

If internal appeals are unsuccessful:

Eligibility:

  • Disputed amount exceeds $500
  • All internal appeals exhausted
  • Request within 4 months of final denial

Process:

Timeline: 45 days standard, 72 hours for urgent cases

From our advocates: "We've seen Skyrizi appeals succeed when prescribers include detailed PASI scores before and after prior TNF inhibitor trials, clearly documenting inadequate response. A comprehensive medical necessity letter citing FDA labeling and dermatology guidelines significantly strengthens the case."

Specialty Pharmacy Requirements

Why CVS Specialty?

Aetna requires most specialty medications, including Skyrizi, to be dispensed through their contracted specialty pharmacy network. CVS Specialty is the primary network pharmacy for most Aetna plans.

Enrollment Process

  1. Provider submits prescription to CVS Specialty after PA approval
  2. Patient completes CVS Specialty enrollment form
  3. Coordinate delivery to home or infusion center
  4. Schedule injection training if needed

CVS Specialty Contact: 1-800-237-2767

Home Delivery and Support

  • Free shipping to home or physician office
  • Cold-chain temperature monitoring
  • 24/7 pharmacist support
  • Injection training and supplies included

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements by analyzing denial letters and crafting targeted, evidence-backed appeals that align with payer policies and clinical guidelines.

Timeline Expectations

Process Step Standard Timeline Expedited Timeline
Prior Authorization Decision 30-45 days 72 hours
Internal Appeal Decision 30-60 days 72 hours
External Review Decision 45 days 72 hours
CVS Specialty Processing 3-7 days after approval Same
First Dose Delivery 1-2 weeks after enrollment Priority shipping

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
"Not medically necessary" Submit severity documentation PASI ≥10, BSA ≥10%, or PGA ≥3
"Step therapy not met" Document TNF inhibitor failure Detailed prior therapy records
"Incomplete TB screening" Submit complete screening TST/IGRA + chest X-ray if indicated
"Non-formulary drug" Request formulary exception Medical necessity letter + alternatives tried
"Quantity limits exceeded" Provide FDA dosing rationale Prescriber attestation of appropriate dosing

FAQ

How long does Aetna prior authorization take for Skyrizi in Florida? Standard PA decisions take 30-45 days. Expedited reviews for urgent medical situations are completed within 72 hours.

What if Skyrizi is not on my Aetna formulary? Request a formulary exception by submitting a medical necessity letter documenting why Skyrizi is medically necessary and why formulary alternatives are inappropriate.

Can I appeal if my Skyrizi PA is denied? Yes. You have 180 days to file an internal appeal with Aetna. If unsuccessful, you can request external review through Florida's Department of Financial Services.

Does step therapy apply if I failed TNF inhibitors in another state? Yes. Prior therapy failures from any state count toward step therapy requirements, as long as you have adequate documentation.

What's the difference between expedited and standard appeals? Expedited appeals are for urgent medical situations where delay could jeopardize health. They're decided within 72 hours versus 30-60 days for standard appeals.

Can I use manufacturer copay assistance with Aetna? Yes, if you have commercial Aetna coverage. Medicare, Medicaid, and other government plan beneficiaries are not eligible for manufacturer copay programs.

When facing complex insurance denials, Counterforce Health specializes in turning insurance denials into successful appeals by identifying specific denial reasons and crafting point-by-point rebuttals using the right clinical evidence and payer-specific requirements.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice and should not replace consultation with your healthcare provider or insurance representative. Coverage policies and requirements may change. Always verify current requirements with Aetna and consult official policy documents for the most up-to-date information.

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