By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (Risankizumab) Covered by Aetna CVS Health in New Jersey: Complete Guide with Forms and Appeals

Answer Box: Getting Skyrizi Covered by Aetna CVS Health in New Jersey

Aetna CVS Health requires prior authorization for Skyrizi (risankizumab) with documented TNF inhibitor failure for psoriasis. Submit requests via Availity portal at least 2 weeks in advance. If denied, you have 180 days to appeal internally, then file external review with New Jersey's IHCAP program administered by Maximus Federal Services. Start today: Gather your insurance card, prior treatment records, and have your dermatologist document psoriasis severity (PASI ≥10, BSA ≥10%, DLQI >10) plus TNF inhibitor failures.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Clinician Corner: Medical Necessity Documentation
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Playbook for New Jersey
  6. Costs & Patient Support Programs
  7. FAQ
  8. Sources & Further Reading

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Must be approved before dispensing Submit 2+ weeks early via Availity Aetna Precert List
Step Therapy TNF inhibitor failure required Document inadequate response/intolerance to Humira, Enbrel, etc. Aetna PA Requirements
Severity Documentation Moderate-severe psoriasis PASI ≥10, BSA ≥10%, DLQI >10 Skyrizi HCP Guidelines
TB Screening Negative QuantiFERON + chest X-ray Complete within 3 months before start CDC TB Guidelines
Appeals Deadline File within 180 days of denial Count from denial letter date NJ IHCAP Portal

Step-by-Step: Fastest Path to Approval

1. Gather Your Documentation (Patient)

Timeline: 1-2 days
You'll need:

  • Insurance card with member ID
  • Complete list of psoriasis treatments tried (dates, outcomes)
  • Recent lab results and photos showing severity
  • Prior denial letters if reapplying

2. Schedule Provider Visit (Patient + Clinic)

Timeline: Within 1 week
Your dermatologist will:

  • Calculate PASI score, BSA percentage, DLQI score
  • Order TB screening (QuantiFERON + chest X-ray)
  • Document step therapy failures in detail
  • Submit via: Availity portal or fax

3. Prior Authorization Submission (Clinic)

Timeline: 2-3 business days for review
Required documents:

  • Medical necessity letter with severity metrics
  • Chart notes showing TNF inhibitor trials/failures
  • TB screening results (negative)
  • Prescription with NDC/J-code

4. Track Decision (Patient + Clinic)

Timeline: 24-48 hours for most requests
If approved: Prescription processed through CVS Specialty If denied: Move immediately to appeals process

5. Internal Appeal (If Denied)

Timeline: 30-45 days for standard, 72 hours for expedited
Submit to: Aetna appeals department with updated clinical documentation Include: Peer-reviewed studies supporting Skyrizi efficacy

6. External Review with New Jersey IHCAP

Timeline: 45 days for standard, expedited available
File at: IHCAP portal or call 888-866-6205 Required: Completed internal appeals, medical records, consent forms

7. Start Treatment

Timeline: 1-2 weeks after approval
Coordinate: CVS Specialty delivery, injection training, monitoring plan

Clinician Corner: Medical Necessity Documentation

Essential Letter Components

When drafting a medical necessity letter for Skyrizi, include these evidence-based elements from official templates:

Patient Demographics & Diagnosis

  • Full name, DOB, insurance ID
  • ICD-10: L40.0 (plaque psoriasis)
  • Duration of condition

Severity Metrics (Document All Three)

  • PASI Score: ≥10 for moderate, ≥12 for severe psoriasis
  • Body Surface Area (BSA): ≥10% affected
  • Dermatology Life Quality Index (DLQI): >10 indicating severe impact

Step Therapy Documentation Per Aetna's requirements, document failure, inadequate response, or contraindication to:

  • TNF inhibitors: adalimumab (Humira), etanercept (Enbrel)
  • Other biologics tried: ustekinumab (Stelara), secukinumab (Cosentyx)
  • Conventional therapies: methotrexate, cyclosporine, phototherapy

Clinical Rationale

  • Risk of progression without treatment
  • Impact on quality of life and function
  • Skyrizi's mechanism (IL-23 p19 inhibition) and superior efficacy data
  • Safety profile appropriate for patient

TB Screening Results

  • QuantiFERON negative (preferred over TST)
  • Chest X-ray normal within 3 months
  • No active TB symptoms or risk factors
From Our Advocates: We've seen the strongest approvals when providers quantify the functional impact—like "unable to work due to hand/foot lesions" or "psoriatic arthritis limiting daily activities." Specific, measurable outcomes resonate more than general statements about "severe psoriasis."

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"Step therapy not completed" Document TNF inhibitor failures Chart notes with dates, outcomes, side effects for each trial
"Not medically necessary" Strengthen severity documentation Updated PASI, BSA, DLQI scores; functional impact assessment
"Experimental/investigational" Cite FDA approval and guidelines FDA label, AAD/NPF guidelines
"Non-formulary" Request formulary exception Comparative effectiveness data vs. formulary alternatives
"Quantity limits exceeded" Justify dosing frequency Clinical rationale for q12w maintenance dosing

Appeals Playbook for New Jersey

Internal Appeals with Aetna CVS Health

Level 1: Standard Appeal

  • Deadline: 180 days from denial
  • Timeline: 30 days for decision (45 days for group plans)
  • Submit: Written request with new clinical evidence
  • Contact: Use member services number on insurance card

Level 2: Expedited Appeal

  • When to use: Urgent medical need, delay could jeopardize health
  • Timeline: 72 hours for decision
  • Submit: Provider must certify urgency in writing

External Review: New Jersey IHCAP

After completing Aetna's internal appeals, New Jersey residents can file with the Independent Health Care Appeals Program:

Eligibility Requirements

  • Fully insured NJ plan or NJ FamilyCare/Medicaid
  • Denial based on medical necessity or experimental designation
  • Internal appeals completed or waived by plan

Filing Process

  1. Register at IHCAP portal as patient or provider
  2. Upload documents: Original denial, internal appeal decisions, medical records
  3. Include consent forms: Authorization for release of records
  4. Submit electronically or mail to Maximus IHCAP

Contact Information

Timeline

  • Standard review: 45 calendar days
  • Expedited review: 48 hours
  • Decision is binding on insurance plan

Cost

  • No fee to patients—insurers pay all costs

Costs & Patient Support Programs

Manufacturer Support

Skyrizi Complete Program

  • Phone: 1-877-266-7538
  • Services: Benefit verification, prior authorization support, copay assistance
  • Eligibility: Most commercial insurance plans

Financial Assistance

  • Copay cards: May reduce out-of-pocket to as low as $5/month
  • Patient assistance programs: For uninsured/underinsured patients
  • Foundation grants: Available through organizations like Good Days, Patient Access Network

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform ingests denial letters and plan policies, then drafts point-by-point rebuttals aligned to each payer's specific requirements—saving time and improving approval rates for complex specialty medications like Skyrizi.

State Resources

New Jersey residents can contact:

  • NJ Department of Banking and Insurance: 1-800-446-7467
  • Consumer assistance: IHCAP hotline 1-888-393-1062

FAQ

How long does Aetna CVS Health prior authorization take for Skyrizi? Most requests are approved within 24-48 hours when submitted with complete documentation via the Availity portal. Incomplete submissions may take longer.

What if Skyrizi is non-formulary on my Aetna plan? Request a formulary exception by documenting that covered alternatives are less effective or cause adverse effects. Include comparative efficacy data and clinical rationale.

Can I request an expedited appeal in New Jersey? Yes, both Aetna (72-hour timeline) and NJ IHCAP (48-hour timeline) offer expedited reviews when delays could jeopardize your health. Your provider must certify the urgency.

Does step therapy apply if I failed TNF inhibitors outside New Jersey? Yes, documented failures from any state count toward step therapy requirements. Ensure your new provider has complete records from previous treatment.

What happens if IHCAP overturns Aetna's denial? The decision is legally binding. Aetna must cover Skyrizi as determined by the independent medical reviewers. This is mandated by New Jersey statute.

How much does Skyrizi cost without insurance? List price is approximately $20,000+ annually. Patient assistance programs and manufacturer coupons can significantly reduce costs—contact Skyrizi Complete at 1-877-266-7538.

Can my provider file the IHCAP appeal for me? Yes, providers can file external appeals on behalf of patients with proper consent forms. This is often more efficient as they have direct access to medical records.

What if I need Skyrizi for Crohn's disease instead of psoriasis? The prior authorization process is similar, but step therapy requirements may include different medications (anti-TNFs, vedolizumab). Document biologic failures specific to IBD treatment.

Through platforms like Counterforce Health, the appeals process becomes more strategic and data-driven, helping ensure that medically necessary treatments like Skyrizi reach the patients who need them most.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies and appeal procedures may change—verify current requirements with official sources listed above.

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