By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (Risankizumab) Covered by Humana in New Jersey: Prior Authorization, Appeals & Step Therapy Guide

Answer Box: Getting Skyrizi Covered by Humana in New Jersey

Skyrizi (risankizumab) is covered by Humana Medicare Advantage plans in New Jersey as a Tier 5 specialty drug requiring prior authorization. The fastest path to approval: 1) Have your doctor submit a complete PA request with diagnosis documentation, prior TNF inhibitor failures, and TB screening results to Humana's Medication Intake Team at 1-888-447-3430. 2) If denied, file an internal appeal within 60 days. 3) For final denials, request an external review through New Jersey's IHCAP program via Maximus—over 80% of specialty drug appeals are overturned. Start today by gathering your insurance card, prior therapy records, and asking your doctor to complete the medical necessity documentation.

Table of Contents

Humana Plan Types & Coverage Implications

Humana operates primarily Medicare Advantage and Part D plans in New Jersey, with some commercial employer coverage. Your plan type affects your appeal rights and external review options:

  • Medicare Advantage: Follow Medicare appeal timelines (60 days for coverage determinations, 7 days for Part D drug appeals)
  • Commercial plans: Subject to New Jersey's Independent Health Care Appeals Program (IHCAP) for external review
  • Self-funded employer plans: May follow different federal appeal processes
Tip: Check your insurance card for "Medicare" designation or call Humana member services at the number on your card to confirm your plan type and appeal rights.

Skyrizi Formulary Status & Tier Placement

Skyrizi is included on Humana's 2024 formularies but placement varies by specific plan:

Plan Component Status Details
Formulary Status Covered Listed on Super National-5 and Premier PDPs
Tier Placement Tier 5 (Specialty) Highest cost-sharing tier
Prior Authorization Required Must be approved before dispensing
Quantity Limits Yes 2 pens per 84 days (standard)
Step Therapy Often required TNF inhibitor trial typically needed first

Source: Humana Drug Lists

Prior Authorization & Step Therapy Requirements

Step Therapy Protocol

Humana typically requires documented failure of at least one TNF inhibitor before approving Skyrizi for psoriasis, psoriatic arthritis, or inflammatory bowel disease. Required trials include:

  • Adalimumab (Humira), etanercept (Enbrel), or infliximab (Remicade)
  • Minimum 3-month trial unless contraindicated or causing adverse events
  • Documentation of inadequate response or intolerance

Medical Necessity Criteria

Your doctor must document:

  1. Confirmed diagnosis with appropriate ICD-10 codes
  2. Disease severity requiring biologic therapy
  3. Prior conventional therapy failures (topical treatments, methotrexate, etc.)
  4. TNF inhibitor trial results and reasons for discontinuation
  5. Tuberculosis screening within the past year
  6. Baseline laboratory values (liver function tests)

Specialty Pharmacy Partners & Setup

Skyrizi must be dispensed through Humana's specialty pharmacy network. Approved partners include:

Pharmacy Phone Fax Network Status
CVS Specialty 800-237-2767 800-323-2445 Primary partner
Accredo 866-759-1557 888-302-1028 Network partner
CenterWell Specialty 800-486-2668 877-405-7940 Humana-owned

Patient Enrollment Process

  1. Prescription Transfer: Your doctor sends the prescription directly to your chosen specialty pharmacy
  2. Benefits Verification: Pharmacy contacts you to verify insurance and begin PA process
  3. Financial Counseling: Assistance with copay programs and patient assistance applications
  4. Medication Shipment: Direct delivery to your home with temperature-controlled packaging
  5. Ongoing Support: Refill coordination and clinical monitoring

Source: Humana Specialty Pharmacy

Cost-Share Basics for Tier 5 Drugs

Specialty tier medications like Skyrizi typically have the highest out-of-pocket costs:

  • Medicare Part D: 25-33% coinsurance until catastrophic coverage
  • Medicare Advantage: Plan-specific copays, often $100-400+ per fill
  • Commercial plans: 20-40% coinsurance after deductible
Financial Assistance: AbbVie offers the Skyrizi Complete program with potential copay support. Visit Skyrizi.com or call 1-877-COMPLETE for eligibility screening.

Submission Process & Required Forms

Primary Submission Route

Fax completed PA requests to: 1-888-447-3430 (Humana Medication Intake Team)

Required Documentation

  • Humana General Prior Authorization Form or drug-specific form
  • Physician medical necessity letter (detailed template below)
  • Clinical notes supporting diagnosis and prior treatments
  • Laboratory results including TB screening
  • Pharmacy records showing previous medication trials

Timeline Expectations

  • Standard Review: 14-30 days
  • Expedited Review: 24-72 hours (requires clinical urgency documentation)
  • Renewal Submissions: Submit 60-90 days before expiration

Source: Humana Prior Authorization

Medical Necessity Documentation

Physician Letter Template - Key Elements

Your doctor's letter should include:

  1. Patient Information: Demographics, insurance details, diagnosis with ICD-10 codes
  2. Clinical History: Disease duration, severity measures, impact on daily function
  3. Prior Treatments: Specific medications tried, dates, outcomes, reasons for discontinuation
  4. Current Status: Disease activity, laboratory values, functional assessment
  5. Medical Necessity Rationale: Why Skyrizi is appropriate, reference to treatment guidelines
  6. Safety Monitoring: TB screening date and results, planned monitoring schedule
  7. Provider Credentials: Contact information, specialty certification, signature

TB Screening Requirements

Documentation must include recent negative TB test within 12 months:

  • QuantiFERON-TB Gold or T-SPOT.TB (preferred)
  • Tuberculin skin test (TST) if interferon-gamma release assays unavailable
  • Chest X-ray within 3 months of initiation

If positive or indeterminate, include evaluation and treatment plan per CDC guidelines.

Appeals Process in New Jersey

Internal Appeals (First Level)

  • Deadline: 60 days from denial notice
  • Method: Online portal, phone (800-457-4708), or written request
  • Required: Original denial letter, additional supporting documentation
  • Timeline: 30 days for standard, 72 hours for expedited

External Review via IHCAP

If Humana upholds the denial, New Jersey residents can request an Independent Health Care Appeals Program (IHCAP) review:

  • Administrator: Maximus Federal Services (contracted by NJ Department of Banking and Insurance)
  • Deadline: 180 days from final internal denial
  • Cost: Free to patients (insurers pay all fees)
  • Success Rate: Over 80% of specialty drug appeals are overturned nationally
  • Timeline: 45 days for standard review, expedited available for urgent cases

IHCAP Contact Information:

Source: New Jersey IHCAP Process

Common Denial Reasons & Solutions

Denial Reason Required Documentation Submission Tips
Insufficient medical necessity Detailed clinical notes, severity scores, functional impact measures Include validated assessment tools (PASI, DAS28, CDAI)
Step therapy not met Complete pharmacy records, prior auth approvals, failure documentation Document specific reasons for discontinuation (side effects, lack of efficacy)
Missing TB screening Recent TB test results, chest X-ray, infectious disease consult if needed Ensure tests are within required timeframes
Non-formulary status Formulary exception request, comparative effectiveness data Highlight contraindications or failures with preferred alternatives
Quantity limit exceeded Clinical justification for higher dosing, weight-based calculations Reference FDA labeling for approved dosing ranges

Clinician Corner: Strengthening Your PA Request

Medical Necessity Checklist:Document specific psoriasis severity (PASI score >10) or joint damage in PsAList all prior systemic therapies with dates, duration, and specific outcomesInclude relevant comorbidities that limit treatment optionsReference current treatment guidelines (AAD, ACR, AGA as appropriate)Provide recent laboratory values and safety monitoring planAddress any formulary restrictions with clinical rationale

Key Guideline References:

From Our Advocates

"We've seen that Humana denials for Skyrizi often center on incomplete step therapy documentation. The most successful appeals include pharmacy printouts showing exact dates of TNF inhibitor trials, specific side effects experienced, and clear documentation of treatment failure. Don't just state 'patient failed Humira'—include the trial duration, highest dose reached, any dose adjustments, and the specific clinical measures that showed inadequate response. This level of detail significantly improves approval chances."

FAQ

How long does Humana prior authorization take for Skyrizi in New Jersey? Standard PA reviews take 14-30 days. Expedited reviews (with clinical urgency documentation) can be completed in 24-72 hours. Submit renewals 60-90 days before expiration to avoid treatment gaps.

What if Skyrizi is not on my Humana formulary? Request a formulary exception through the standard PA process. Include documentation of medical necessity and contraindications or failures with preferred alternatives on the formulary.

Can I request an expedited appeal if denied? Yes, if treatment delay would seriously jeopardize your health. Your doctor must provide clinical documentation supporting the urgent need for therapy.

Does New Jersey step therapy apply if I failed TNF inhibitors in another state? Yes, pharmacy records and clinical documentation from any state are acceptable to satisfy step therapy requirements, as long as they're properly documented and verifiable.

What's the success rate for Humana appeals in New Jersey? Nationally, 81.7% of Humana prior authorization appeals were overturned in 2023. New Jersey's external review process through IHCAP shows similarly high success rates for medically necessary specialty drugs.

How does Counterforce Health help with Humana appeals? Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with Humana's specific requirements, significantly improving approval chances.

What to Gather Before You Start

Patient Information:

  • Insurance card with member ID
  • Prior authorization denial letters (if applicable)
  • Complete list of current medications
  • Previous specialty pharmacy information

Medical Records:

  • Diagnosis documentation with ICD-10 codes
  • Prior treatment history with dates and outcomes
  • Recent laboratory results (within 6 months)
  • TB screening results (within 12 months)
  • Functional assessment scores or severity measures

Provider Information:

  • Prescribing physician contact details
  • Specialty certification information
  • Preferred specialty pharmacy choice

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies navigate complex insurance approval processes for prescription drugs. Their evidence-based platform transforms denials into successful appeals by identifying specific denial reasons and crafting targeted responses aligned with each payer's unique requirements. Learn more at CounterforceHealth.org.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage policies change frequently. Always verify current requirements with Humana directly and consult with your healthcare provider regarding appropriate treatment decisions. For personalized assistance with insurance appeals, consider consulting with patient advocacy services or organizations like Counterforce Health that specialize in coverage determination processes.

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