By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (risankizumab) Covered by Blue Cross Blue Shield of Michigan: Prior Authorization Guide and Appeals Process

Quick Answer: Getting Skyrizi Covered by Blue Cross Blue Shield of Michigan

Blue Cross Blue Shield of Michigan requires prior authorization for Skyrizi (risankizumab) with specific step therapy requirements. For Crohn's disease, you need documented failure of conventional therapy (steroids for ≥7 days, immunomodulators for ≥2 months). Submit the BCBSM Medication Authorization Request Form with clinical documentation. Standard approval takes up to 15 days; expedited reviews are completed within 72 hours. If denied, you have internal appeal rights plus Michigan's external review process through DIFS within 127 days.

Start today: Contact your prescriber to begin gathering documentation of prior therapy failures and diagnosis confirmation.

Table of Contents

  1. Why Michigan State Rules Matter
  2. BCBSM Prior Authorization Requirements
  3. Step Therapy and Medical Exception Criteria
  4. Fastest Path to Approval
  5. Appeals Process in Michigan
  6. External Review Through Michigan DIFS
  7. Common Denial Reasons and Solutions
  8. Cost Assistance and Patient Support
  9. FAQ

Why Michigan State Rules Matter

Michigan's insurance laws provide strong consumer protections that work alongside Blue Cross Blue Shield of Michigan's (BCBSM) plan policies. Under Michigan law MCL 500.3406o, insurers using drug formularies must "provide for exceptions to the formulary limitations when a nonformulary alternative is a medically necessary and appropriate alternative."

Michigan's Patient's Right to Independent Review Act (PRIRA) gives you binding external appeal rights after internal plan appeals. The state also requires specific timelines for prior authorization decisions under MCL 500.2212c.

Note: These protections apply to fully-insured BCBSM plans but may not cover self-funded employer plans governed by ERISA.

BCBSM Prior Authorization Requirements

Coverage Criteria for Skyrizi

BCBSM requires prior authorization for Skyrizi (risankizumab-rzaa, HCPCS J2327) with specific coverage criteria:

Requirement Details
Diagnosis FDA-approved indications: Crohn's disease, plaque psoriasis, psoriatic arthritis, ulcerative colitis
Age Limits Per FDA labeling (typically adults)
Step Therapy Must document failure of conventional therapy
Quantity Limits Aligns with FDA-recommended dosing
Authorization Period 1 year
Renewal Documentation of ongoing benefit required

Required Documentation

Submit these materials with your BCBSM Medication Authorization Request Form:

  • Confirmed diagnosis with ICD-10 codes
  • Documentation of prior therapy failures
  • Clinical notes showing disease severity
  • Relevant lab results and screening (TB, hepatitis B)
  • Treatment goals and monitoring plan

Step Therapy and Medical Exception Criteria

Standard Step Therapy Requirements

For Crohn's disease, BCBSM requires documented inadequate response, intolerance, or contraindication to:

  1. Steroids for at least 7 days
  2. Immunomodulators (e.g., azathioprine) for at least 2 months

Medical Exception Criteria

Michigan Medicaid step therapy override criteria provide a framework that many plans follow:

  • Allergy to preferred medications
  • Contraindication or drug-drug interaction
  • History of unacceptable side effects
  • Patient clinically stable where switching would cause deterioration
  • Therapeutic failure on preferred medication
Tip: Document specific reasons for each failed therapy (lack of efficacy vs. adverse effects vs. contraindications) with dates and dosages.

Fastest Path to Approval

Step-by-Step Process

  1. Verify Coverage (Patient/Clinic)
    • Check your specific BCBSM plan formulary
    • Confirm whether commercial, Medicare Advantage, or Medicaid
    • Timeline: Same day
  2. Gather Documentation (Prescriber)
    • Collect records of prior therapy failures
    • Document current disease severity
    • Obtain required lab screenings
    • Timeline: 1-3 days
  3. Submit Prior Authorization (Prescriber)
    • Complete BCBSM PA form
    • Submit via provider portal or fax
    • Timeline: Same day
  4. BCBSM Review
    • Standard review: Up to 15 calendar days
    • Expedited review: Within 72 hours (if urgent)
    • Timeline: Per BCBSM policy
  5. If Approved
    • Authorization valid for 1 year
    • Obtain medication through designated specialty pharmacy

Expedited Review Criteria

Request expedited review when delay would "seriously jeopardize the member's health" with physician documentation of urgency.

Appeals Process in Michigan

Internal Appeals with BCBSM

If your initial request is denied:

Appeal Level Timeline to File BCBSM Decision Time Required Documents
First Level Within 60 days of denial 30 days (standard)
72 hours (urgent)		 Denial letter, medical necessity letter, clinical records
Final Internal Per plan documents Per plan timeline Updated documentation addressing denial reasons

Required Elements for Appeal Letter

Your physician's appeal letter should include:

  • Patient and provider identification
  • Specific service/medication denied
  • Detailed medical necessity justification
  • Response to each denial reason
  • Supporting clinical evidence and guidelines
  • For urgent cases: explanation of health jeopardy from delay

External Review Through Michigan DIFS

When to File External Review

After receiving BCBSM's final internal denial, you can request external review through Michigan DIFS for medical necessity denials.

Key Timelines and Requirements

Aspect Standard Review Expedited Review
Filing Deadline Within 127 days of final denial Same
Decision Time Within statutory timeframe (typically 45-60 days) Within 72 hours
Eligibility Medical necessity denials Pre-service denials with physician urgency letter
Cost Free to consumer Free to consumer

How to File

  1. Use DIFS External Review Form
  2. Required Documents
    • Copy of BCBSM's final denial letter
    • Your reasons for appealing
    • Physician letter of medical necessity
    • All relevant medical records
    • Insurance card and policy information
  3. For Expedited Review
    • Physician letter stating delay would "jeopardize life, health, or ability to regain maximum function"
    • Specific clinical reasons supporting urgency
Important: DIFS decisions are binding on BCBSM. If DIFS overturns the denial, BCBSM must provide coverage.

Common Denial Reasons and Solutions

Denial Reason Solution Strategy Required Documentation
Insufficient step therapy Document all prior therapy failures with specific dates, doses, outcomes Pharmacy records, physician notes, treatment timeline
Lack of medical necessity Provide detailed clinical justification with guideline support Disease severity scores, specialist consultation, evidence-based guidelines
Missing lab results Submit required screening results TB testing, hepatitis B screening per BCBSM criteria
Experimental/investigational Demonstrate FDA approval for your specific indication FDA labeling, clinical trial data, specialty society guidelines

Cost Assistance and Patient Support

Manufacturer Support Programs

AbbVie offers patient assistance through:

  • AbbVie Care: Copay assistance and patient support services
  • Patient Assistance Program: For uninsured/underinsured patients
  • Contact: Visit AbbVie Care website or call patient support

State and Foundation Resources

  • Michigan Department of Health and Human Services: Medicaid coverage information
  • Patient Access Network Foundation: Copay assistance for qualifying conditions
  • HealthWell Foundation: Financial assistance for chronic conditions

Practical Scripts and Templates

Phone Script for BCBSM Member Services

"I'm calling about a prior authorization denial for Skyrizi (risankizumab) for [condition]. I'd like to request the specific medical policy used to deny coverage and information about filing an internal appeal. My member ID is [number] and the denial letter is dated [date]."

Peer-to-Peer Request Script

"I'm requesting a peer-to-peer review for my patient's Skyrizi prior authorization denial. The patient has documented failure of [specific prior therapies] and meets medical necessity criteria per [specific guidelines]. When can we schedule the clinical review?"

Frequently Asked Questions

Q: How long does BCBSM prior authorization take for Skyrizi? A: Standard review takes up to 15 calendar days. Expedited review (when medically urgent) takes up to 72 hours per BCBSM policy.

Q: What if Skyrizi isn't on my BCBSM formulary? A: You can request a formulary exception under Michigan law MCL 500.3406o when the medication is medically necessary. Submit documentation showing why formulary alternatives are inappropriate.

Q: Can I appeal to Michigan DIFS if BCBSM denies my appeal? A: Yes, Michigan's PRIRA allows external review through DIFS within 127 days of BCBSM's final internal denial for medical necessity decisions.

Q: Do I need to complete step therapy if I've failed similar medications with another insurer? A: Document prior failures with pharmacy records and physician notes. BCBSM may accept this as meeting step therapy requirements.

Q: What's the difference between standard and expedited appeals? A: Expedited appeals are for urgent situations where delay could jeopardize health. They require physician documentation of urgency and are decided within 72 hours.

Q: Can my doctor file appeals on my behalf? A: Yes, physicians can file appeals as your authorized representative. Michigan law allows this with proper consent.

When to Contact Michigan DIFS

Contact Michigan DIFS Consumer Services (877-999-6442) if:

  • BCBSM doesn't respond to appeals within required timeframes
  • You need help understanding your appeal rights
  • You want to file a complaint about plan practices
  • You need assistance with the external review process

Counterforce Health: Expert Appeal Support

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed appeals. Our platform identifies the specific denial basis and drafts point-by-point rebuttals aligned to each plan's own rules, pulling the right clinical evidence and meeting payer-specific procedural requirements to reduce back-and-forth and improve approval rates.

Medical Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions and work with them to navigate insurance coverage requirements.

Sources & Further Reading:

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