By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (Risankizumab) Covered by Cigna in North Carolina: Complete Appeals Guide with Forms and Timelines

Quick Answer: Getting Skyrizi (risankizumab) covered by Cigna in North Carolina requires prior authorization through Express Scripts/Accredo. Submit via CoverMyMeds portal with clinical documentation showing disease severity (PASI ≥10 or BSA ≥10% for psoriasis) and prior systemic therapy failures. If denied, appeal through Cigna's internal process, then North Carolina's Smart NC external review program within 120 days. Start by gathering your diagnosis codes, prior treatment records, and TB screening results today.

Table of Contents

Understanding Cigna's Skyrizi Coverage

Cigna covers Skyrizi (risankizumab) for FDA-approved indications including plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis, but prior authorization is mandatory for all formulations. As a specialty biologic, Skyrizi is typically managed through Express Scripts/Accredo specialty pharmacy and requires comprehensive clinical documentation before approval.

The medication faces common coverage hurdles including step therapy requirements (trying other biologics first), medical necessity documentation, and tuberculosis screening verification. However, with proper preparation and documentation, most clinically appropriate requests receive approval.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters and crafting evidence-backed rebuttals aligned to each plan's specific policies. Their platform helps patients and clinicians navigate complex prior authorization requirements like those for Skyrizi with Cigna.

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation (Patient & Clinic)

  • Insurance card with Cigna member ID
  • Complete diagnosis with ICD-10 codes
  • Prior treatment history with dates, durations, and outcomes
  • Recent TB screening results (TST or IGRA within 12 months)
  • Current lab values and clinical notes
  • Timeline: 1-2 business days

2. Complete Prior Authorization Form (Prescriber)

Access the Cigna prior authorization portal or use CoverMyMeds at covermymeds.com. Include:

  • Patient demographics and Cigna ID
  • Prescriber information and NPI
  • Skyrizi dosing, quantity, and administration site
  • Clinical justification with severity scores
  • Timeline: 30-60 minutes

3. Submit Through Preferred Portal (Clinic Staff)

Primary options:

  • CoverMyMeds: Most efficient electronic submission
  • Surescripts: Through your EHR system
  • Accredo iAssist: Via myaccredopatients.com
  • Fax backup: 855-840-1678 for paper forms
  • Timeline: Same day submission

4. Monitor Status and Respond to Requests (Ongoing)

Check portal daily for status updates or requests for additional information. Cigna typically responds within 5 business days for standard reviews.

  • Timeline: 3-7 business days for initial decision

5. Appeal if Denied (Patient & Prescriber)

If denied, immediately request internal appeal through Cigna member services at 1-800-244-6224. Gather additional clinical evidence and consider peer-to-peer review.

  • Timeline: 30 days to file internal appeal

6. External Review Through Smart NC (If Needed)

After exhausting Cigna's internal appeals, file external review with North Carolina's Smart NC program at 1-855-408-1212.

  • Timeline: 120 days from final Cigna denial

Coverage Requirements at a Glance

Requirement What It Means Documentation Needed Source
Prior Authorization Mandatory for all Skyrizi formulations Completed PA form with clinical notes Cigna PA Policy
Disease Severity PASI ≥10 or BSA ≥10% for psoriasis Clinical documentation with scores FDA Label Requirements
Step Therapy Prior systemic therapy trial required Treatment history with dates/outcomes Cigna Coverage Policy
TB Screening Negative test within 12 months TST or IGRA results FDA Safety Requirements
Specialist Prescriber Dermatologist, GI, or rheumatologist Provider credentials verification Cigna PA Form
Appeals Deadline 180 days for internal appeals Denial letter and supporting evidence Cigna Member Guide

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Insufficient severity documentation Submit PASI scores, BSA measurements, or functional impact scores Clinical notes with objective severity measures
Step therapy not met Document prior biologic failures or contraindications Prescription history, adverse event reports, treatment timelines
TB screening incomplete Provide recent negative TB test results TST or IGRA within 12 months, chest X-ray if indicated
Not medically necessary Submit specialty guidelines and clinical studies Peer-reviewed literature, society recommendations
Quantity limits exceeded Justify dosing based on FDA labeling or clinical response Dosing rationale, weight-based calculations
From Our Advocates: We've seen many Cigna Skyrizi denials overturned by providing comprehensive prior treatment documentation. One case involved a psoriasis patient whose initial denial for "insufficient severity" was reversed when the clinic submitted detailed PASI scores and photos showing functional impairment. The key was demonstrating that topical therapies had failed and that the patient met both BSA and quality-of-life criteria.

Appeals Playbook for North Carolina

Internal Appeals with Cigna

Level 1 - Standard Internal Appeal

  • Who files: Patient or authorized representative
  • Deadline: 180 days from denial date
  • How to file: Call 1-800-244-6224 or submit through member portal
  • Timeline: 30 days for standard, 72 hours for urgent
  • Required documents: Denial letter, additional clinical evidence, prescriber letter

Level 2 - Peer-to-Peer Review Request medical director review if Level 1 is denied. Your prescriber can request direct conversation with Cigna's medical director to discuss clinical rationale.

  • Contact: Through provider services or member services
  • Timeline: Typically scheduled within 5-7 business days

External Review Through Smart NC

If Cigna's internal appeals are unsuccessful, North Carolina residents can request binding external review through the state's Smart NC program.

Eligibility Requirements:

  • Exhausted Cigna's internal appeal process (or qualify for expedited review)
  • Denial based on medical necessity or experimental treatment determination
  • State-regulated plan (most individual and small group plans qualify)

How to Apply:

  1. Call Smart NC at 1-855-408-1212 for free assistance
  2. Complete external review request form from NC Department of Insurance
  3. Submit within 120 days of Cigna's final denial
  4. Include all clinical documentation and prescriber support letter

Timeline:

  • Standard review: 45 days maximum
  • Expedited review: 72 hours for urgent cases
  • Decision is binding: Cigna must provide coverage if overturned
Note: Smart NC provides free advocacy assistance and can help you gather supporting documentation and complete forms correctly.

Medical Necessity Documentation

Essential Components for Prescriber Letter

Patient Background:

  • Complete diagnosis with ICD-10 codes
  • Disease duration and progression
  • Current severity measures (PASI, BSA, quality of life scores)
  • Functional impairment documentation

Prior Treatment History:

  • All previous therapies with specific names, doses, durations
  • Reasons for discontinuation (lack of efficacy, adverse events, contraindications)
  • Documentation of adequate trial periods

Clinical Rationale:

  • Why Skyrizi is medically necessary for this patient
  • Expected outcomes and treatment goals
  • Supporting literature from peer-reviewed sources
  • Specialty society guideline references

Safety Considerations:

  • TB screening results with dates
  • Contraindications to alternative therapies
  • Monitoring plan during treatment

When to Request Peer-to-Peer Review

Request a peer-to-peer review when:

  • Initial denial cites medical necessity concerns
  • Step therapy requirements seem inappropriate for your patient
  • Clinical circumstances don't fit standard coverage criteria
  • You have strong guideline support for off-label use

Key Talking Points for Medical Directors:

  • Emphasize patient-specific factors that make Skyrizi appropriate
  • Reference FDA labeling and specialty society guidelines
  • Highlight prior treatment failures with specific details
  • Address safety considerations, particularly TB screening compliance
  • Discuss expected outcomes and monitoring plan

For complex cases requiring detailed evidence analysis and appeal strategy, Counterforce Health helps transform denial letters into targeted, evidence-backed appeals that address each plan's specific coverage criteria.

Patient Support and Cost Assistance

AbbVie Patient Support:

  • Skyrizi Complete program provides coverage investigation and prior authorization support
  • Copay assistance for eligible patients (typically $5-10 per dose)
  • Free drug programs for uninsured patients meeting income criteria
  • Contact: 1-866-SKYRIZI (1-866-759-7494)

Additional Resources:

  • Patient Access Network Foundation grants for specialty biologics
  • HealthWell Foundation assistance programs
  • State pharmaceutical assistance programs (verify North Carolina eligibility)

Frequently Asked Questions

How long does Cigna prior authorization take for Skyrizi in North Carolina? Standard prior authorization typically takes 5-7 business days. Urgent requests can be processed within 72 hours if clinical urgency is documented.

What if Skyrizi is not on Cigna's formulary? You can request a formulary exception through the same prior authorization process. Include clinical justification for why formulary alternatives are inappropriate.

Can I request expedited appeal in North Carolina? Yes, both Cigna and Smart NC offer expedited reviews for urgent medical situations. Document how delays would seriously jeopardize health outcomes.

Does step therapy apply if I failed biologics in another state? Yes, prior treatment history from other states counts toward step therapy requirements. Provide complete documentation of previous therapies and outcomes.

What happens if Smart NC external review is denied? The external review decision is final for administrative appeals, but you may have other legal rights. Consult with a healthcare attorney if needed.

How do I prove medical necessity for off-label Skyrizi use? Provide peer-reviewed literature, specialty society guidelines, and detailed clinical rationale. Document why FDA-approved alternatives are inappropriate.

Can my doctor appeal on my behalf? Yes, prescribers can file appeals as your authorized representative. Many practices have dedicated staff for insurance appeals and prior authorizations.

What if I need Skyrizi while traveling outside North Carolina? Contact Cigna member services to arrange temporary out-of-state coverage. Accredo specialty pharmacy can coordinate delivery to temporary addresses.

Disclaimer: This information is for educational purposes and does not constitute medical or legal advice. Coverage policies change frequently—always verify current requirements with Cigna and consult your healthcare provider for medical decisions.

Sources & Further Reading:

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