By Counterforce Health Team in Skyrizi (risankizumab) —

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

Answer Box: Getting Skyrizi (risankizumab) Covered

To get Skyrizi covered by Aetna CVS Health in Illinois: Your doctor must submit a prior authorization showing you meet medical necessity criteria—typically moderate-to-severe disease and documented failure or intolerance to at least one TNF inhibitor (like Humira). The process takes 30-45 days for standard reviews. If denied, you have 180 days to file an internal appeal, followed by external review through Illinois' independent review process. Start today: Ask your prescriber to gather documentation of prior treatment failures and submit the PA request through Aetna's provider portal.

Table of Contents

Coverage Basics

Is Skyrizi covered by Aetna CVS Health? Yes, but it requires prior authorization and must be dispensed through CVS Specialty Pharmacy. Skyrizi is classified as a specialty tier medication for all Aetna plans in Illinois.

Which Aetna plans cover Skyrizi?

  • Commercial/Employer plans: Covered with prior authorization
  • Aetna Better Health of Illinois (Medicaid): Covered with no patient cost after PA approval
  • Medicare plans: Coverage varies by specific plan formulary
Note: For Illinois Medicaid members, there's no out-of-pocket cost for covered specialty medications, but prior authorization is still required.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Gather Required Documentation (Patient/Clinic)
    • Complete medical records showing diagnosis
    • Documentation of prior TNF inhibitor trials and outcomes
    • Current disease severity measurements (PASI score, BSA affected, joint counts)
    • Recent lab work including TB screening
  2. Provider Submits PA Request (Prescriber)
    • Complete Aetna's prior authorization form
    • Submit through Aetna provider portal or fax
    • Include all supporting clinical documentation
    • Timeline: Submit as soon as treatment decision is made
  3. Aetna Review Process (30-45 days)
    • Medical director reviews against published criteria
    • May request additional information
    • Decision communicated to provider and patient
  4. If Approved (Provider/Patient)
    • Prescription sent to CVS Specialty Pharmacy
    • Patient contacted for delivery coordination
    • Treatment can begin upon receipt
Tip: For urgent cases, request an expedited review, which must be completed within 72 hours for serious health risks.

Medical Necessity Requirements

Aetna's medical necessity criteria for Skyrizi vary by condition:

Coverage at a Glance

Requirement Plaque Psoriasis Psoriatic Arthritis Crohn's Disease
Age Adult (18+) Adult (18+) Adult (18+)
Severity ≥10% BSA OR ≥3% BSA + failed systemic therapy Active disease Moderate-to-severe activity
Prior Therapy Biologic OR crucial area involvement May require DMARD/biologic failure As clinically appropriate
Documentation BSA measurement, location Joint counts, prior treatments CDAI score, endoscopic findings

Key Documentation Requirements

For all conditions, your doctor must document:

  • Confirmed diagnosis with appropriate ICD-10 codes
  • Disease severity using validated measures
  • Prior treatment history and reasons for discontinuation
  • Contraindications to other therapies (if applicable)
  • Treatment goals and monitoring plan

Psoriasis-specific requirements:

  • Body surface area (BSA) percentage affected
  • Involvement of "crucial areas" (hands, feet, face, genitals)
  • Failed response to phototherapy or systemic drugs (methotrexate, cyclosporine)

Timeline and Status Tracking

Expected Timelines

  • Standard PA decision: 30-45 days
  • Expedited review: 72 hours (for urgent medical situations)
  • Additional information requests: May extend timeline by 14 days

Tracking Your Request

Monitor your prior authorization status through:

  • CVS Caremark member portal (create account at caremark.com)
  • Provider communication (your doctor receives updates)
  • Phone: Call member services number on your insurance card

Counterforce Health helps patients navigate complex prior authorization requirements by analyzing denial letters and creating targeted, evidence-based appeals that address specific payer criteria. Their platform can identify the exact documentation needed to meet Aetna's requirements and draft compelling medical necessity letters.

Costs and Financial Assistance

Out-of-Pocket Costs by Plan Type

Plan Type Patient Cost Notes
Aetna Medicaid IL $0 No copay for covered drugs
Commercial Plans Varies by plan Specialty tier copay/coinsurance
Medicare Plan-specific Check formulary for tier placement

Savings Options

  • AbbVie Copay Card: May reduce commercial insurance copays to $5 per dose (Medicaid/Medicare ineligible)
  • Patient assistance programs: Available through AbbVie for qualifying uninsured/underinsured patients
  • Foundation grants: Organizations like PAN Foundation may assist with copays
Important: Copay assistance programs cannot be used with government insurance (Medicaid, Medicare).

Common Denial Reasons and Solutions

Denial Reason What It Means How to Fix It
"Not medically necessary" Doesn't meet severity criteria Submit PASI scores, BSA measurements, photos
"Step therapy not met" Must try other drugs first Document TNF inhibitor trials and failures
"Experimental/investigational" Not FDA-approved for indication Provide FDA labeling for your specific condition
"Non-formulary" Not on preferred drug list Request formulary exception with clinical justification

Strengthening Your Case

When resubmitting or appealing, include:

  • Peer-reviewed studies supporting Skyrizi for your condition
  • Professional society guidelines (AAD, ACR, AGA)
  • Detailed treatment timeline showing prior failures
  • Letter from specialist explaining medical necessity

Illinois Appeals Process

Illinois provides robust patient protections under the Health Carrier External Review Act. Here's your roadmap:

Internal Appeal (First Step)

  • Deadline: 180 days from denial
  • Timeline: Aetna has 30 days for pre-service, 60 days for post-service decisions
  • How to file: Submit written appeal to address on denial letter
  • Required: Copy of denial letter, medical records, physician letter

External Review (If Internal Appeal Fails)

  • Deadline: 4 months after final internal denial
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Process: Independent physician reviewer with relevant specialty
  • Cost: Free to patients (insurers pay review fees)
  • Decision: Binding on Aetna if overturned

Illinois-Specific Resources

  • Illinois Department of Insurance: File external review
  • Consumer assistance: 877-527-9431
  • Attorney General Health Care Bureau: 1-877-305-5145
Critical: Illinois has a shorter external review deadline (4 months) compared to many states. Don't delay if your internal appeal is denied.

CVS Specialty Pharmacy Requirements

All Aetna members must use CVS Specialty Pharmacy for Skyrizi. Here's what to expect:

Automatic Transfer Process

  • Active prescriptions with refills transfer automatically
  • Prior authorizations should transfer with prescriptions
  • You'll receive notification if any action is needed

Patient Portal Features

  • Track prescription status and delivery
  • View prior authorization approval status
  • Manage refills and delivery preferences
  • Access medication information and support

What to Do If Transfer Issues Occur

  1. Contact CVS Specialty: Call the number provided in transfer communications
  2. Have your doctor resubmit: If PA doesn't transfer, provider may need to resubmit
  3. Request expedited processing: For urgent situations

Troubleshooting Common Issues

"My prior authorization is taking too long"

  • Standard timeline: 30-45 days is normal
  • Follow up: Contact your provider to check for information requests
  • Expedite if urgent: Request expedited review for serious health risks

"I can't access the patient portal"

  • CVS Caremark portal issues: Try clearing browser cache or use mobile app
  • Account setup: May need insurance card and personal information to register
  • Alternative: Call member services for status updates

"My prescription was denied after approval"

  • Formulary changes: Mid-year changes can affect coverage
  • Quantity limits: May need additional approval for higher doses
  • Renewal required: Some approvals have time limits requiring reauthorization

FAQ: Your Most Common Questions

Q: How long does Aetna prior authorization take for Skyrizi in Illinois? A: Standard reviews take 30-45 days. Expedited reviews for urgent situations must be completed within 72 hours.

Q: What if Skyrizi isn't on Aetna's formulary? A: Your doctor can request a formulary exception by demonstrating medical necessity and providing clinical justification for why preferred alternatives aren't appropriate.

Q: Can I appeal an Aetna denial in Illinois? A: Yes. You have 180 days to file an internal appeal, then 4 months for external review through Illinois' independent review process if the internal appeal fails.

Q: Does step therapy apply if I failed TNF inhibitors outside Illinois? A: Yes, prior treatment failures from other states count toward step therapy requirements as long as they're properly documented in your medical records.

Q: What's the difference between CVS Caremark and CVS Specialty? A: CVS Caremark manages your pharmacy benefits, while CVS Specialty is the required pharmacy for dispensing Skyrizi and other specialty medications.

Q: How do I know if my Skyrizi is covered under Aetna Medicaid? A: Illinois Medicaid covers Skyrizi with prior authorization. Once approved, there's no cost to you. Check the current formulary for status.

Q: Can I get a temporary supply while waiting for approval? A: Some plans offer transition fills or emergency supplies. Contact member services to ask about temporary coverage options.

Q: What happens if I move from Illinois to another state? A: Coverage may change based on state-specific Aetna policies. Contact member services before relocating to understand any differences in coverage or requirements.

From our advocates: "We've seen many Skyrizi denials overturned when patients provide thorough documentation of TNF inhibitor failures. The key is showing not just that you tried other medications, but specifically why they didn't work—whether due to lack of effectiveness, side effects, or loss of response over time. This detailed history, combined with current severity measures, creates a compelling case for medical necessity."

About Counterforce Health

Counterforce Health specializes in turning insurance denials into successful appeals for patients, clinicians, and specialty pharmacies. The platform analyzes denial letters, identifies specific payer requirements, and creates evidence-backed appeals that address each plan's criteria point-by-point. For complex prior authorizations like Skyrizi, Counterforce Health can help gather the right clinical evidence and craft compelling medical necessity arguments that improve approval rates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies and requirements can change. Always verify current requirements with your insurance plan and consult your healthcare provider for medical decisions. For personalized assistance with Illinois insurance issues, contact the Illinois Department of Insurance at 877-527-9431.

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