By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (risankizumab) Covered by Cigna in Pennsylvania: Prior Authorization, Appeals, and Alternative Options

Quick Answer: Getting Skyrizi (risankizumab) Covered by Cigna in Pennsylvania

Skyrizi is excluded from the 2024 Express Scripts National Preferred Formulary, which most Cigna commercial plans follow. To get coverage in Pennsylvania, you'll need a formulary exception with documented failure of preferred alternatives like Humira, Cosentyx, or Tremfya. Submit through your prescriber within 72 hours for standard review. If denied, Pennsylvania's new external review program has a 50% success rate overturning insurance denials. Start by working with your doctor to document prior treatment failures and submit a prior authorization request.

Table of Contents

When Alternatives Make Sense

Since Skyrizi (risankizumab) is excluded from most Cigna formularies through Express Scripts, understanding when formulary alternatives might work for your condition is crucial. The good news? Several effective biologics remain preferred and could provide similar benefits.

Coverage Criteria at a Glance:

Requirement What It Means Where to Find It
Prior Authorization Required for all biologics Cigna provider portal
Step Therapy Must try preferred options first Express Scripts formulary
Tuberculosis Screening Negative TB test required FDA prescribing information
Specialty Pharmacy Dispensed through Accredo/Express Scripts Member ID card
Diagnosis Documentation ICD-10 codes for psoriasis, PsA, IBD Clinical notes

Formulary alternatives make sense when:

  • You haven't tried other biologics yet
  • Previous biologics failed due to efficacy, not safety issues
  • Your condition is stable and switching is medically appropriate
  • You want to avoid the formulary exception process initially

However, alternatives may not be suitable if you have documented allergies, specific contraindications, or have already cycled through multiple biologics unsuccessfully.

Typical Formulary Alternatives

Cigna's preferred biologics for psoriasis, psoriatic arthritis, and inflammatory bowel disease typically include:

For Plaque Psoriasis and Psoriatic Arthritis:

  • Humira (adalimumab) - TNF inhibitor, often first-line
  • Cosentyx (secukinumab) - IL-17A inhibitor
  • Taltz (ixekizumab) - IL-17A inhibitor
  • Tremfya (guselkumab) - IL-23 inhibitor (same class as Skyrizi)
  • Stelara (ustekinumab) - IL-12/23 inhibitor

For Crohn's Disease and Ulcerative Colitis:

  • Humira (adalimumab) - TNF inhibitor
  • Remicade (infliximab) - TNF inhibitor
  • Stelara (ustekinumab) - IL-12/23 inhibitor
  • Entyvio (vedolizumab) - Gut-selective integrin inhibitor
Note: Tremfya (guselkumab) targets the same IL-23 pathway as Skyrizi and may provide similar efficacy for psoriasis and psoriatic arthritis.

Pros and Cons Overview

Advantages of Trying Alternatives First:

  • Faster access (no formulary exception needed)
  • Lower out-of-pocket costs on preferred tiers
  • Established safety profiles
  • Similar efficacy for many patients
  • Streamlined pharmacy fulfillment

Considerations:

  • May require different dosing schedules
  • Monitoring requirements vary by drug class
  • Some alternatives require more frequent injections
  • TNF inhibitors have different side effect profiles than IL-23 inhibitors

Access Considerations: All preferred biologics require the same basic safety screening: tuberculosis testing, hepatitis B screening, and complete blood count. The monitoring burden is generally similar across drug classes.

Exception Strategy for Skyrizi

When formulary alternatives aren't appropriate, requesting a formulary exception for Skyrizi requires strategic documentation. Here's what strengthens your case:

Step-by-Step Exception Process:

  1. Gather Documentation (1-2 days)
    • Previous biologic trial records with dates
    • Documented failures, adverse events, or contraindications
    • Current disease severity scores (PASI for psoriasis, clinical notes for IBD)
  2. Prescriber Submits Request (Same day)
    • Via Cigna provider portal or fax to 866-873-8279
    • Include clinical rationale addressing medical necessity
    • Attach supporting documentation
  3. Cigna Review (72 hours standard, 24 hours expedited)
    • Clinical pharmacist or medical director review
    • May request additional information
  4. Response and Next Steps (Immediate upon decision)
    • Approval: Coverage at non-preferred tier pricing
    • Denial: Written explanation with appeal rights

Medical Necessity Documentation Should Include:

  • Specific prior biologics tried with start/stop dates
  • Reasons for discontinuation (lack of efficacy, adverse events, contraindications)
  • Objective measures of treatment failure (PASI scores, endoscopy results, lab values)
  • Why Skyrizi is medically necessary over alternatives
  • Relevant clinical guidelines supporting use
From our advocates: We've seen the strongest exception approvals when prescribers include specific efficacy data (like PASI scores before/after previous treatments) and cite peer-reviewed evidence showing Skyrizi's unique benefits for the patient's specific clinical situation. Generic statements about "patient preference" rarely succeed.

Switching Logistics

Coordinating a switch between biologics—whether to an alternative or to Skyrizi after approval—requires careful timing and communication.

Before Switching:

  • Schedule washout period if medically appropriate (typically 4-12 weeks depending on drug half-life)
  • Update tuberculosis screening if more than 12 months old
  • Coordinate with specialty pharmacy for new drug fulfillment
  • Verify insurance authorization is active

During the Switch:

  • Monitor for disease flare during washout period
  • Have rescue therapy plan if symptoms worsen
  • Track response with objective measures
  • Document any adverse events or efficacy issues

Pharmacy Coordination: Most Cigna plans use Accredo or Express Scripts specialty pharmacy. Contact them directly at the number on your member ID card to:

  • Transfer prescriptions between specialty pharmacies
  • Verify prior authorization status
  • Arrange delivery timing
  • Access patient support programs

Re-trying for Skyrizi Later

If you start with a formulary alternative, documenting the trial properly positions you for a stronger Skyrizi exception request later.

What to Document During Alternative Trials:

  • Baseline disease severity scores
  • Treatment response at 12, 16, and 24 weeks
  • Any adverse events or tolerability issues
  • Objective measures of partial or complete treatment failure
  • Impact on quality of life and functional status

When to Request Skyrizi:

  • After adequate trial duration (typically 3-6 months for biologics)
  • If response is inadequate despite optimization
  • If adverse events limit continued use
  • If contraindications develop to current therapy

Strengthening Your Case: The more alternatives you've tried with documented outcomes, the stronger your medical necessity case becomes. Keep detailed records and work with your prescriber to quantify treatment responses.

For complex cases involving multiple biologic failures, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific policies.

Appeals Process in Pennsylvania

Pennsylvania offers one of the strongest appeals processes in the nation, with a new external review program that overturned 50% of appealed denials in its first year.

Internal Appeals with Cigna:

  • Deadline: 180 days from denial notice
  • Timeline: 30 days for standard review, 72 hours for expedited
  • How to file: Written request via member portal or mail
  • Required: Original denial letter, supporting medical records, prescriber statement

Pennsylvania External Review: After exhausting internal appeals, you can request external review through the Pennsylvania Insurance Department:

  • Deadline: 4 months after final internal denial
  • Timeline: 45 days for standard review, 72 hours for expedited
  • Success rate: 50.1% of appeals overturned in 2024
  • Cost: Free to consumers
  • How to file: Online at pa.gov or call 1-877-881-6388

Required for External Review:

  • Final Adverse Benefit Determination letter from Cigna
  • All supporting medical documentation
  • Completed external review application
  • Any additional evidence within 15 days of IRO assignment

The Independent Review Organization (IRO) assigns a physician in the same specialty as your condition to review the case. Their decision is binding on Cigna—if they overturn the denial, Cigna must provide coverage immediately.

FAQ

How long does Cigna prior authorization take in Pennsylvania? Standard prior authorization decisions are required within 72 hours. Expedited reviews (when delay would jeopardize health) must be completed within 24 hours.

What if Skyrizi is completely non-formulary on my plan? You can still request a formulary exception. The process is the same—your prescriber must demonstrate medical necessity and why covered alternatives aren't appropriate.

Can I request an expedited appeal in Pennsylvania? Yes, if continuing your current treatment or starting Skyrizi is urgent for your health. Both Cigna internal appeals and Pennsylvania external review offer expedited timelines.

Does step therapy apply if I failed biologics outside Pennsylvania? Yes, documented failures from previous insurance or other states count toward step therapy requirements. Ensure your new prescriber has complete records from previous treatments.

How much does Skyrizi cost if approved by Cigna? As a non-preferred specialty drug, expect higher copays or coinsurance. AbbVie offers copay assistance programs that may reduce out-of-pocket costs to as low as $5 per month for eligible patients.

What counts as adequate trial of an alternative biologic? Most payers require 3-6 months of treatment at appropriate doses, unless contraindications or serious adverse events occur earlier.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies vary by specific plan and change frequently. Always verify current requirements with Cigna directly and consult your healthcare provider for medical decisions. For personalized help with complex appeals, Counterforce Health provides specialized assistance in navigating insurance coverage challenges for prescription medications.

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