By Counterforce Health Team in Skyrizi (risankizumab) —

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

Answer Box: Get Skyrizi Covered by Aetna CVS Health in Georgia

Fastest Path to Approval: Aetna CVS Health requires prior authorization for Skyrizi (risankizumab) with specific medical necessity criteria by condition. Your prescriber must submit documentation showing disease severity, failed conventional treatments, and specialist oversight. If denied, you have 180 days for internal appeals, then 4 months for Georgia's free external review through independent reviewers. Start today: Have your dermatologist, rheumatologist, or gastroenterologist gather your treatment history and submit the Aetna Skyrizi precertification form.

Table of Contents

  1. Aetna's Coverage Policy Overview
  2. Medical Necessity Requirements by Condition
  3. Step Therapy and Exception Pathways
  4. Quantity Limits and Renewal Requirements
  5. Required Diagnostics and Documentation
  6. CVS Specialty Pharmacy Requirements
  7. Evidence to Support Medical Necessity
  8. Sample Medical Necessity Narrative
  9. Appeals Process in Georgia
  10. Common Denial Reasons and Solutions
  11. FAQ

Aetna's Coverage Policy Overview

Aetna CVS Health covers Skyrizi (risankizumab) across all plan types—HMO, PPO, and Medicaid—but requires mandatory prior authorization for all indications. The medication must be dispensed through CVS Specialty Pharmacy for commercial plans.

Plan Types and Coverage:

  • Commercial Plans: Full coverage after PA approval; CVS Specialty required
  • Medicare Part D: Standard PA requirements apply; 72-hour decision timeline
  • Medicaid (Aetna Better Health): No patient cost-sharing after approval

All requests must be submitted electronically as of June 2023, with standard decisions taking 30-45 days and expedited reviews available within 72 hours for urgent situations.

Medical Necessity Requirements by Condition

Plaque Psoriasis

Required Criteria:

  • Diagnosis of moderate-to-severe plaque psoriasis
  • ≥10% body surface area (BSA) affected OR ≥3% BSA with failed systemic therapy
  • Involvement of critical areas (hands, feet, face, genitals) if BSA <10%
  • Prescriber must be dermatologist or in consultation with one
  • Age ≥18 years

Documentation Needed:

  • BSA measurements and severity assessment
  • Prior treatment failures with topical therapies, phototherapy, or systemic agents
  • Clinical photographs (if available)

Psoriatic Arthritis

Required Criteria:

  • Active psoriatic arthritis meeting diagnostic criteria
  • Failed or intolerant to ≥1 non-biologic DMARD (methotrexate, sulfasalazine, leflunomide)
  • Rheumatologist or dermatologist prescriber
  • Age ≥18 years

Documentation Needed:

  • Joint counts and functional assessment
  • Previous DMARD trial outcomes
  • Imaging studies showing joint involvement

Crohn's Disease

Required Criteria:

  • Moderately-to-severely active Crohn's disease (CDAI >220)
  • Failed ≥1 conventional therapy AND ≥1 TNF inhibitor
  • Gastroenterologist prescriber required
  • Age ≥18 years

Documentation Needed:

  • CDAI scores and endoscopic findings
  • Detailed biologic failure history
  • Objective disease activity measures

Step Therapy and Exception Pathways

Aetna typically requires evidence of conventional therapy failure before approving Skyrizi. However, formulary exceptions are available when step therapy is inappropriate.

Exception Criteria:

  • Medical contraindication to preferred agents
  • History of severe adverse reactions
  • Drug interactions with current medications
  • Clinical urgency requiring immediate biologic therapy

How to Request Exception:

  1. Contact Aetna at 1-866-752-7021 (providers) or member services
  2. Submit detailed clinical rationale from specialist
  3. Include documentation of contraindications or prior failures
  4. Request expedited review if clinically urgent

Quantity Limits and Renewal Requirements

Formulation Quantity Limit Frequency Renewal Requirements
Subcutaneous (psoriasis) 150 mg (2 × 75mg) Week 0, 4, then q12w Annual PA renewal with response documentation
Subcutaneous (arthritis) 150 mg Week 0, 4, then q12w Clinical assessment every 6 months
IV (Crohn's induction) 600 mg × 3 doses Weeks 0, 4, 8 Switch to SC maintenance after induction
SC (Crohn's maintenance) 180 mg Every 8 weeks CDAI improvement required for renewal

Renewal Documentation:

  • Objective improvement measures (BSA reduction, joint counts, CDAI scores)
  • Tolerability assessment
  • Continued medical necessity statement from specialist

Required Diagnostics and Documentation

Pre-Treatment Screening

  • Tuberculosis screening: Chest X-ray, tuberculin skin test or interferon-gamma release assay
  • Hepatitis B/C screening: HBsAg, anti-HBc, anti-HCV
  • Complete blood count with differential
  • Liver function tests

Disease-Specific Requirements

  • Psoriasis: PASI score, BSA measurements, quality of life assessments
  • Psoriatic Arthritis: Joint counts, HAQ-DI, imaging studies
  • Crohn's Disease: CDAI, CRP, fecal calprotectin, colonoscopy findings

Documentation Tips:

  • Include lab values with reference ranges and dates
  • Provide imaging reports, not just "abnormal" notations
  • Document timing of assessments relative to treatment failures

CVS Specialty Pharmacy Requirements

Aetna requires Skyrizi to be dispensed through CVS Specialty Pharmacy for most commercial plans. Key requirements:

Site-of-Care Restrictions:

  • IV induction: Preference for office/ambulatory infusion centers over hospital outpatient
  • SC maintenance: Home self-administration preferred
  • Hospital infusion only for: new starts, clinical instability, or documented complications

CVS Specialty Process:

  1. Provider submits PA to Aetna
  2. After approval, prescription routed to CVS Specialty
  3. Patient contacted for benefits verification and shipping
  4. Clinical support available through CVS Specialty pharmacists

Contact Information:

  • CVS Specialty: 1-800-237-2767
  • Provider support: 1-866-814-5506

Evidence to Support Medical Necessity

Clinical Guidelines to Reference

  • American Academy of Dermatology: Psoriasis treatment guidelines support IL-23 inhibitors for moderate-to-severe disease
  • American College of Rheumatology: Biologic therapy recommendations for psoriatic arthritis
  • American Gastroenterological Association: IBD treatment algorithms including IL-23 targeting

Key Studies to Cite

  • ADVANCE trial: Demonstrated efficacy in biologic-experienced Crohn's patients
  • UltIMMa-1 and UltIMMa-2: Phase 3 psoriasis trials showing superior efficacy vs. placebo
  • KEEPsAKE 1 and 2: Psoriatic arthritis efficacy and safety data

How to Cite in Appeals:

"Per the ADVANCE trial published in NEJM (2022), risankizumab demonstrated significant clinical remission rates in patients with prior biologic failure, supporting its use in this biologic-experienced patient."

Sample Medical Necessity Narrative

Medical Necessity Statement for Skyrizi (Risankizumab) - Crohn's Disease

This 34-year-old patient has moderately-to-severely active Crohn's disease (CDAI 280, CRP 15 mg/L) with ileocolonic involvement confirmed by colonoscopy on [date]. Despite adequate trials of mesalamine (failed due to inadequate response), azathioprine (discontinued due to leukopenia), and adalimumab (primary non-response after 12 weeks), the patient continues to experience active inflammation with frequent bloody stools, abdominal pain, and weight loss.

Risankizumab is FDA-approved for moderately-to-severely active Crohn's disease and has demonstrated efficacy in biologic-experienced patients per the ADVANCE trial. The patient meets all coverage criteria: age >18, gastroenterologist management, documented conventional and biologic therapy failures, and objective disease activity measures. Alternative IL-23 inhibitors are not formulary-preferred, and continued delay in effective therapy risks complications including hospitalization and surgery.

Appeals Process in Georgia

Internal Appeals with Aetna

  • Timeline: 180 days from denial date to file
  • Standard Review: 30-45 days for decision
  • Expedited Review: 72 hours for urgent situations
  • Submission: Aetna member portal, fax to 1-888-267-3277, or mail

Georgia External Review

After internal appeal denial, Georgia residents can request independent external review:

  • Timeline: Must file within 4 months of final Aetna denial
  • Process: Request through healthcare.gov external review or assigned IRO
  • Decision Timeline: 45 days standard, 72 hours expedited
  • Cost: Free to consumer; binding on Aetna if approved

Georgia Consumer Support:

Common Denial Reasons and Solutions

Denial Reason Solution Documentation Needed
"Not medically necessary" Provide disease severity measures and specialist assessment CDAI >220, BSA >10%, or joint counts with functional impact
"Step therapy not met" Document failures/contraindications to preferred agents Detailed prior treatment timeline with outcomes and adverse effects
"Experimental/investigational" Cite FDA approval and clinical guidelines FDA label indication, AGA/ACR/AAD guideline support
"Quantity exceeds limit" Request exception with clinical rationale Specialist letter explaining dosing rationale and monitoring plan
"Non-formulary drug" Submit formulary exception request Comparative effectiveness data vs. formulary alternatives

FAQ

How long does Aetna CVS Health prior authorization take in Georgia? Standard PA decisions take 30-45 days. Expedited reviews for urgent situations are completed within 72 hours. Submit requests electronically through the provider portal for fastest processing.

What if Skyrizi is non-formulary on my Aetna plan? You can request a formulary exception if formulary alternatives are ineffective or cause adverse effects. Your prescriber must provide clinical justification within 72 hours of the request.

Can I request an expedited appeal in Georgia? Yes, both Aetna internal appeals and Georgia external reviews offer expedited timelines (72 hours) if delays would seriously jeopardize your health. Explicitly request expedited review and provide supporting documentation.

Does step therapy apply if I failed biologics outside Georgia? Yes, documented biologic failures from any state count toward meeting step therapy requirements. Ensure your new Georgia provider has complete treatment records from previous physicians.

What happens if Aetna denies my external review appeal? Georgia's external review decision is binding on Aetna—they must cover the medication if the independent reviewer approves. This ends the administrative process; further disputes would require legal action.

How much will Skyrizi cost with Aetna coverage? Costs depend on your specific plan's specialty drug copay or coinsurance. After PA approval, typical costs range from $50-200/month copay to 10-25% coinsurance. Check with CVS Specialty for exact amounts.

From our advocates: "We've seen denials overturned when providers include specific CDAI scores, prior biologic duration and response details, and cite the ADVANCE trial data. The key is showing objective disease measures and comprehensive treatment history—not just listing medications tried. Georgia's external review process has been particularly effective for specialty biologics when internal appeals fail."

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters, identifies the specific denial basis, and drafts point-by-point rebuttals aligned to each payer's own rules, pulling the right clinical evidence and procedural requirements to maximize approval chances.

Sources & Further Reading

Disclaimer: This guide provides educational information about insurance coverage processes and should not be considered medical or legal advice. Always consult your healthcare provider for medical decisions and review your specific insurance policy for coverage details. For personalized assistance with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

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