By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (risankizumab) Covered by Cigna in New Jersey: Complete Prior Authorization Guide

Answer Box: Getting Skyrizi (risankizumab) Covered by Cigna in New Jersey

Eligibility: Skyrizi requires prior authorization from Cigna for moderate-to-severe plaque psoriasis, psoriatic arthritis, Crohn's disease, or ulcerative colitis. You must document failure of preferred biologics (typically TNF inhibitors like Humira) and meet severity criteria (PASI ≥10 or BSA ≥10%).

Fastest path: Submit PA via CoverMyMeds with complete clinical documentation. Standard decisions within 72 hours.

First step today: Contact your prescriber to gather records of prior therapy failures and current severity scores. If denied, New Jersey's IHCAP external review (via Maximus Federal Services at 1-888-393-1062) has strong overturn rates within 45 days.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Common Denial Reasons & How to Fix Them
  4. Appeals Process for Cigna in New Jersey
  5. Medical Necessity Documentation
  6. Costs & Patient Support Programs
  7. FAQ: Skyrizi Coverage Questions

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization PA required for all indications Complete PA form via CoverMyMeds or fax Cigna PA Policy
Step Therapy Must fail preferred biologics first Medical records showing TNF inhibitor failure Cigna Coverage Criteria
Severity Requirements PASI ≥10, BSA ≥10%, or moderate-severe PGA Clinical assessment with numeric scores Cigna Psoriasis Policy
Specialty Pharmacy Dispensed through Accredo Prescription sent to Accredo NCPDP 4436920 Accredo Referral Forms
TB Screening Negative TB test required Lab results and chest imaging FDA Label Requirements

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient/Clinic)

Timeline: 1-2 business days
Documents needed:

  • Insurance card and policy details
  • Complete medical records from prior biologic treatments
  • Current PASI score, BSA assessment, or PGA rating
  • TB screening results (chest X-ray, QuantiFERON Gold)

2. Submit Prior Authorization (Prescriber)

Timeline: Same day submission
How to submit:

  • Preferred: CoverMyMeds portal (fastest processing)
  • Alternative: Fax Cigna PA form to (855) 840-1678
  • Urgent cases: Call Cigna at (800) 882-4462

Required form: Cigna Skyrizi Prior Authorization Form

3. Prescription to Specialty Pharmacy (Prescriber)

Timeline: Same day as PA submission
How: E-prescribe to Accredo (NCPDP 4436920) or fax Skyrizi Prescription Form to 888.302.1028

4. PA Decision (Cigna)

Timeline: 72 hours for standard review, 24 hours for expedited
Possible outcomes: Approved, denied, or request for additional information

5. Appeal if Denied (Patient/Prescriber)

Timeline: Must appeal within 180 days of denial
Process: Submit to Cigna internal appeals, then IHCAP external review if needed

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Key Documents
"Lack of medical necessity" Submit detailed severity scores (PASI ≥10, BSA ≥10%) and functional impairment documentation Clinical notes with numeric assessments, photos if available
"Step therapy not met" Provide complete records of TNF inhibitor trials with specific failure reasons Treatment logs showing dates, doses, duration, and reason for discontinuation
"Missing TB screening" Submit negative TB test results QuantiFERON Gold or TST results, chest X-ray report
"Non-formulary drug" Request formulary exception with clinical rationale Letter explaining why preferred alternatives are inappropriate
"Quantity limits exceeded" Provide dosing justification based on FDA labeling FDA package insert, weight-based dosing calculations
From Our Advocates: We've seen many Cigna denials overturned when prescribers include specific PASI scores and detailed timelines of prior therapy failures. One composite case involved a patient whose initial denial was reversed after the dermatologist submitted month-by-month treatment logs showing inadequate response to two TNF inhibitors over six months each, along with current PASI documentation.

Appeals Process for Cigna in New Jersey

Internal Appeals (Required First)

Level 1 Internal Appeal

  • Timeline: File within 180 days of denial
  • Decision time: 30 days (or 72 hours if expedited)
  • How to file: Cigna member portal or mail to address on denial letter

Level 2 Internal Appeal

  • Timeline: File within 60 days of Level 1 denial
  • Decision time: 30 days
  • Process: Independent medical review by Cigna

External Review via IHCAP

When to use: After completing both internal appeal levels

  • Timeline: File within 120 days of final internal denial
  • Contact: Maximus Federal Services at 1-888-393-1062
  • Decision time: 45 days (expedited available for urgent cases)
  • Success rate: Approximately 50% of external appeals favor consumers
  • Cost: Free to patients

Required documents for IHCAP:

Note: IHCAP decisions are binding on Cigna. If overturned, Cigna must provide coverage.

Medical Necessity Documentation

Clinician Corner: Essential Elements

Diagnosis Documentation:

  • ICD-10 codes (L40.0 for plaque psoriasis, L40.50 for psoriatic arthritis)
  • Disease duration and progression
  • Current severity assessment with numeric scores

Prior Therapy Documentation:

  • Specific medications tried (generic and brand names)
  • Start and stop dates
  • Maximum doses achieved
  • Objective measures of response or failure
  • Reasons for discontinuation (inefficacy, intolerance, contraindications)

Clinical Rationale for Skyrizi:

  • Why preferred alternatives are inappropriate
  • Patient-specific factors (comorbidities, allergies, lifestyle)
  • Treatment goals and expected outcomes
  • Monitoring plan

Supporting Evidence:

  • Recent clinical guidelines supporting IL-23 inhibitor use
  • FDA labeling for approved indications
  • Peer-reviewed literature when appropriate

Costs & Patient Support Programs

Skyrizi Complete Program

  • Copay assistance: Up to $5 per injection for eligible patients
  • Eligibility: Commercial insurance (not government plans)
  • How to enroll: SkyriziComplete.com or call 1-866-SKYRIZI

Alternative Support Options

  • Patient Access Network Foundation: Grants for specialty medications
  • HealthWell Foundation: Copay assistance for autoimmune conditions
  • State pharmaceutical assistance programs: Contact New Jersey DOBI for state-specific programs

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with each payer's specific requirements.

FAQ: Skyrizi Coverage Questions

How long does Cigna prior authorization take in New Jersey? Standard PA decisions are made within 72 hours. Expedited reviews (for urgent medical situations) are completed within 24 hours. Submit via CoverMyMeds for fastest processing.

What if Skyrizi is non-formulary on my Cigna plan? Request a formulary exception by providing clinical documentation showing why preferred alternatives are inappropriate. Include detailed records of prior therapy failures and contraindications.

Can I request an expedited appeal in New Jersey? Yes, both Cigna internal appeals and IHCAP external reviews offer expedited pathways when delays could cause serious harm to your health. Contact reviewers directly to request expedited processing.

Does step therapy apply if I failed biologics outside New Jersey? Yes, Cigna accepts documentation of prior therapy failures from any state. Ensure medical records clearly document the medications tried, duration, and reasons for discontinuation.

What happens if IHCAP overturns Cigna's denial? IHCAP decisions are legally binding. Cigna must provide coverage for the approved treatment and cannot appeal the external review decision.

How much does Skyrizi cost with Cigna coverage? Costs vary by plan. With prior authorization approval, typical copays range from $30-100 for specialty tier medications. The Skyrizi Complete program can reduce copays to $5 for eligible patients.

When navigating Cigna's prior authorization process in New Jersey, having the right documentation and understanding the appeal pathways significantly improves your chances of approval. Counterforce Health's platform can help streamline this process by identifying specific denial reasons and generating targeted appeals that address Cigna's policy requirements.

For additional support, contact the New Jersey Department of Banking and Insurance Consumer Hotline at 1-800-446-7467 or the IHCAP hotline at 1-888-393-1062.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan for personalized guidance.

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