By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (Risankizumab) Covered by Blue Cross Blue Shield of Illinois: Complete Prior Authorization and Appeals Guide

Quick Answer: Blue Cross Blue Shield of Illinois requires prior authorization for Skyrizi (risankizumab). Submit the Illinois Uniform PA Form through Prime Therapeutics with documented step therapy attempts. If denied, you have 180 days to appeal internally, then 4 months for Illinois external review. Start by calling the number on your insurance card to confirm your specific plan's requirements.

Table of Contents

Understanding Your Blue Cross Blue Shield Illinois Coverage

Blue Cross Blue Shield of Illinois (BCBSIL) classifies Skyrizi as a specialty biologic requiring prior authorization for most commercial and marketplace plans. The medication is managed through Prime Therapeutics, BCBSIL's pharmacy benefit manager.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for most plans BCBSIL PA Lookup Tool
Step Therapy May require failed alternatives Plan-specific formulary
Formulary Tier Specialty tier (high cost-sharing) Member portal or ID card
Site of Care Usually self-injection or infusion center Provider guidelines
Appeals Deadline 180 days from denial Denial letter

Skyrizi (risankizumab) is FDA-approved for moderate-to-severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis. BCBSIL's coverage criteria generally align with these approved indications but often require documented failure of preferred alternatives.

Step-by-Step: Fastest Path to Approval

1. Verify Benefits and Coverage

Who: Patient or clinic staff
Action: Call the number on your BCBSIL ID card
Timeline: Same day
What to ask: Is Skyrizi covered? What's my formulary tier? Are there step therapy requirements?

2. Check Prior Authorization Requirements

Who: Prescriber or clinic
Action: Use the BCBSIL PA lookup tool
Timeline: 5 minutes online
Document: Note specific PA criteria for your plan

3. Complete the Illinois Uniform PA Form

Who: Prescriber
Action: Download and complete the Illinois Uniform Prior Authorization Form
Timeline: 30-60 minutes
Include: Diagnosis, ICD-10 codes, prior treatments, clinical justification

4. Gather Supporting Documentation

Who: Clinic staff
Documents needed:

  • Medical records showing diagnosis severity
  • Documentation of prior therapy failures or contraindications
  • Lab results (if applicable)
  • Clinical notes supporting medical necessity

5. Submit to Prime Therapeutics

Who: Prescriber
Method: Fax to the number listed on the PA form
Timeline: Submit within 24 hours of completion
Follow-up: Call to confirm receipt

6. Track Your Request

Who: Patient and clinic
Timeline: Standard review takes up to 7 business days
Action: Monitor for approval or denial notification

7. If Denied, Prepare Appeal

Who: Prescriber with patient support
Timeline: Must appeal within 180 days of denial
Next step: Follow appeals process below

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Step therapy not met Document failed trials of methotrexate, topicals, or other preferred biologics with specific reasons (inefficacy, intolerance, contraindications)
Insufficient severity documentation Include PASI scores >10, BSA >10%, photographs, functional impairment documentation
Missing clinical information Submit complete medical records, lab results, specialist consultations
Non-formulary status Request formulary exception with medical necessity letter explaining why formulary alternatives are inappropriate
Quantity limits exceeded Provide dosing rationale based on FDA labeling and clinical guidelines
Tip: The most successful appeals address every specific reason mentioned in the denial letter with documented evidence.

Appeals Playbook for Blue Cross Blue Shield Illinois

Internal Appeal (Level 1)

  • Deadline: 180 days from denial date
  • Who can appeal: Patient, prescriber, or authorized representative
  • How to submit: Written request to address on denial letter
  • Timeline: 15 business days for pre-service, 30 days for post-service
  • Required: Original denial letter, new clinical information, medical necessity letter

Expedited Appeal

  • When to use: Urgent medical situations where delay could harm health
  • Timeline: 24 hours for decision
  • How to request: Call member services and state "urgent medical need"

Peer-to-Peer Review

After initial denial, your prescriber can request a peer-to-peer review where they discuss your case directly with a BCBSIL medical director. This often happens before or alongside the formal appeal process.

To schedule: Contact the provider services number on your denial letter within 7-14 days of denial.

Medical Necessity Letter Checklist

When your prescriber writes a medical necessity letter for Skyrizi, it should include:

Patient Information

  • Full name, date of birth, member ID
  • Primary and secondary diagnoses with ICD-10 codes
  • Current symptoms and functional limitations

Clinical Justification

  • Specific FDA-approved indication being treated
  • Disease severity markers (PASI score, Crohn's Disease Activity Index, etc.)
  • Previous treatments tried with specific outcomes
  • Why formulary alternatives are inappropriate
  • Expected treatment goals and monitoring plan

Supporting Evidence

  • Reference to FDA prescribing information
  • Relevant clinical guidelines (American Academy of Dermatology, American Gastroenterological Association)
  • Peer-reviewed literature supporting off-label use (if applicable)
From our advocates: We've seen the highest success rates when prescribers include specific PASI scores or disease activity indices in their letters, along with documented adverse events from previous biologics. One dermatologist noted that including photographs of skin lesions significantly improved approval rates for their psoriasis patients.

Illinois External Review Process

If your internal appeal is denied, Illinois law guarantees your right to an independent external review through the Illinois Health Carrier External Review Act.

Key Details

  • Deadline: 4 months from final internal denial
  • Cost: Free to consumers
  • Reviewer: Board-certified physician with relevant expertise
  • Timeline: Decision within 45 days (expedited within 72 hours)
  • Binding: If approved, BCBSIL must cover the treatment

How to Request

  1. Complete the Request for External Review form
  2. Submit to: Illinois Department of Insurance, 320 W. Washington St., 4th Floor, Springfield, IL 62767
  3. Include all denial letters and supporting medical records

For assistance, contact the Illinois Department of Insurance at 877-527-9431.

Cost-Saving Options

While working through the coverage process, explore these financial assistance options:

AbbVie Patient Support

  • Skyrizi Complete: Copay assistance and patient support program
  • Eligibility: Commercial insurance patients
  • Savings: Up to $5,000 per month in copay assistance
  • Contact: Skyrizi.com or 1-877-SKYRIZI

Foundation Assistance

  • Patient Advocate Foundation
  • Good Days (formerly Chronic Disease Fund)
  • HealthWell Foundation

State Programs

Illinois residents may qualify for pharmaceutical assistance through the Illinois Cares Rx program for certain conditions.

When to Escalate

File a Complaint with Illinois Attorney General

If BCBSIL fails to follow proper procedures or denies coverage inappropriately:

Contact Illinois Department of Insurance

For insurance regulatory issues:

  • Phone: 877-527-9431
  • Online: File complaint through DOI website

Get Professional Help

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, identifying specific coverage criteria, and drafting evidence-backed appeals that address each denial reason point-by-point. Their platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization and appeals processes more effectively.

FAQ

Q: How long does BCBSIL prior authorization take for Skyrizi?
A: Standard reviews take up to 7 business days. Expedited reviews for urgent medical needs are completed within 24 hours.

Q: What if Skyrizi isn't on my formulary?
A: You can request a formulary exception by submitting a medical necessity letter explaining why covered alternatives are inappropriate for your condition.

Q: Can I get an expedited appeal if my condition is worsening?
A: Yes. If delaying treatment could seriously harm your health, request an expedited appeal when calling member services.

Q: Do I need to try other biologics before Skyrizi?
A: This depends on your specific plan's step therapy requirements. Some plans require documented failure of TNF inhibitors or other preferred agents first.

Q: What happens if my external review is approved?
A: BCBSIL must cover your Skyrizi treatment. The external review decision is legally binding.

Q: Can my doctor request a peer-to-peer review?
A: Yes. Your prescriber can request to speak directly with a BCBSIL medical director to discuss your case, often leading to faster resolutions.

Q: What if I have both medical and pharmacy coverage through BCBSIL?
A: Skyrizi coverage depends on how it's administered. Self-injected versions typically go through pharmacy benefits, while IV infusions may be covered under medical benefits.

Sources & Further Reading

Medical Disclaimer: This guide provides general information about insurance coverage and appeals processes. It is not medical advice. Always consult with your healthcare provider about treatment decisions and work with your clinic's prior authorization specialists for plan-specific guidance. Coverage policies change frequently—verify current requirements with your specific BCBSIL plan.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.