By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (risankizumab) Covered by Humana in New York: Prior Authorization Forms, Appeals Process, and Support Resources

Answer Box: Getting Skyrizi Covered by Humana in New York

Skyrizi (risankizumab) requires prior authorization from Humana before coverage. The fastest path to approval: 1) Have your doctor submit the PA request online or by fax to 877-486-2621, 2) Include clinical justification showing medical necessity and any prior treatment failures, 3) Follow up within 72 hours for the decision. If denied, you have 65 days to appeal through Humana's internal process, then potentially federal Medicare appeals (state external appeals don't apply to Medicare plans). Start with Humana's PA portal.

Table of Contents

  1. Verify Your Plan and Coverage
  2. Prior Authorization Forms and Requirements
  3. Submission Portals and Online Access
  4. Fax and Mail Submission Options
  5. Specialty Pharmacy Coordination
  6. Support Phone Lines and Contacts
  7. Appeals Process in New York
  8. When to Update Your Resources

Verify Your Plan and Coverage

Before starting the prior authorization process, confirm your specific Humana plan type. This determines which forms and procedures you'll need to follow.

Check Your Plan Type:

  • Medicare Advantage/Part D: Most common Humana coverage in New York
  • Commercial/Employer Plans: Different PA requirements and timelines
  • Medicaid Managed Care: State-specific processes may apply
Tip: Look at your insurance card for "Medicare" or "MA" indicators, or log into your MyHumana account to verify plan details.

Formulary Status Check: Skyrizi may require prior authorization regardless of formulary placement. Use Humana's drug lookup tool to check coverage tier and restrictions for your specific plan.

Prior Authorization Forms and Requirements

Current Forms (2024-2025)

Primary Form: Humana Medicare Prior Authorization Form - verified current as of August 2025.

Required Documentation:

  • Completed PA form with prescriber signature and NPI
  • Clinical justification letter detailing:
    • Diagnosis with ICD-10 codes (psoriasis L40.9, psoriatic arthritis L40.50, Crohn's disease K50.9)
    • Prior treatment history and failures/intolerances
    • Rationale for Skyrizi specifically
    • Dosing plan and administration schedule
  • Supporting clinical data (labs, imaging, severity assessments)
  • Patient demographics and insurance information

Medical Necessity Criteria

For Plaque Psoriasis:

  • Moderate-to-severe disease (typically BSA >10% or PASI >12)
  • Failed or intolerant to conventional systemic therapy
  • Contraindications to other biologics

For Inflammatory Bowel Disease:

  • Documented moderate-to-severe active disease
  • Inadequate response to conventional therapy
  • Prior biologic failure (plan-dependent)

Submission Portals and Online Access

Provider Portals

Primary Portal: Humana Provider Portal

  • Requires provider registration and credentials
  • Fastest processing times (typically 24-72 hours)
  • Real-time status tracking

CoverMyMeds Integration: Available at www.covermymeds.com/epa/humana

  • Electronic PA submission
  • Automated form population
  • Direct EHR integration for many practices

Member Access

MyHumana Portal: www.humana.com

  • Track PA status
  • Upload additional documentation
  • View coverage determination letters
Note: Members can initiate PA requests but clinical documentation must come from prescribers.

Fax and Mail Submission Options

Fax Numbers

Pharmacy Prior Authorization: 877-486-2621

  • Standard processing: 5-7 business days
  • Include complete documentation package
  • Use cover sheet with patient ID and drug name

Professionally Administered Drugs: 888-447-3430

  • For office/infusion center administration
  • Medical benefit claims (not pharmacy)

Mailing Address

Standard Mail: Humana Pharmacy Services Prior Authorization Department P.O. Box 14601 Lexington, KY 40512

Expedited/Overnight: Humana Pharmacy Services Prior Authorization Department 500 West Main Street Louisville, KY 40202

Cover Sheet Best Practices

Include on every fax:

  • Patient name and Humana ID
  • Drug name (Skyrizi/risankizumab)
  • Prescriber name and NPI
  • Total pages being sent
  • Contact phone for questions

Specialty Pharmacy Coordination

CenterWell Specialty Pharmacy

Provider Contact: 1-800-486-2668 (TTY: 711)

  • Humana's preferred specialty pharmacy
  • Integrated PA processing
  • Patient education and support services

Transfer Process:

  1. Complete PA approval first
  2. Contact CenterWell to initiate enrollment
  3. Provide prescription and insurance information
  4. Coordinate delivery and administration training

Alternative Specialty Pharmacies

If using a non-preferred specialty pharmacy:

  • Confirm network status with Humana
  • May require additional documentation
  • Potentially higher out-of-pocket costs

Support Phone Lines and Contacts

For Healthcare Providers

Clinical Pharmacy Review: 1-800-555-CLIN (2546)

  • Monday-Friday, 8 AM-8 PM local time
  • PA status inquiries
  • Clinical consultation requests
  • Peer-to-peer review scheduling

Provider Services: 866-488-5995

  • General coverage questions
  • Policy interpretation
  • Technical portal support

For Patients and Caregivers

Member Services: Use the number on your Humana ID card

  • PA status updates
  • Coverage explanations
  • Appeal assistance

Medicare-Specific: 866-773-5959

  • Medicare Advantage and Part D questions
  • Formulary exceptions
  • Appeal rights explanation

Key Questions to Ask

When calling Humana support:

  • "What specific documentation is missing for my Skyrizi PA?"
  • "Can you schedule a peer-to-peer review with my doctor?"
  • "What are my appeal rights if this is denied?"
  • "Is there an expedited review process available?"

Appeals Process in New York

Important Limitation for Medicare Plans

Critical Note: If you have Humana Medicare coverage, you are not eligible for New York State external appeals through the Department of Financial Services. Medicare beneficiaries must use federal Medicare appeal procedures.

Internal Appeals with Humana

Timeline: 65 days from denial date to file Process:

  1. Submit written appeal to address on denial letter
  2. Include additional clinical evidence
  3. Request expedited review if medically urgent
  4. Receive decision within 30 days (72 hours if expedited)

Medicare Appeal Levels

Level 1: Humana internal reconsideration (60 days) Level 2: Independent Review Entity (60 days) Level 3: Administrative Law Judge (60 days) Level 4: Medicare Appeals Council (60 days) Level 5: Federal District Court (60 days)

For Non-Medicare Humana Plans

Commercial plan members may be eligible for New York State external appeals after exhausting internal appeals:

  • 4-month deadline after final denial
  • $25 fee (waived for financial hardship)
  • Independent medical review
  • Binding decision on insurer

When to Update Your Resources

Quarterly Checks (Every 3 Months)

  • Verify current PA form versions
  • Check formulary updates
  • Confirm portal access and passwords
  • Review any policy changes

Annual Updates (January)

  • New plan year formulary changes
  • Updated medical necessity criteria
  • Revised appeal deadlines
  • Contact number changes

Immediate Updates Needed When:

  • Denial letters reference outdated forms
  • Portal access is denied
  • Phone numbers are disconnected
  • New FDA indications are approved for Skyrizi

Getting Help: Counterforce Health Support

Navigating insurance approvals for specialty medications like Skyrizi can be overwhelming, especially when dealing with complex prior authorization requirements and potential appeals. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to identify the specific denial basis and draft point-by-point rebuttals.

The platform helps patients and clinicians gather the right evidence—FDA labeling, peer-reviewed studies, and specialty guidelines—and weaves them into appeals that align with each payer's specific requirements and procedural workflows.

Frequently Asked Questions

Q: How long does Humana take to approve Skyrizi prior authorization? A: Generally 72 hours after receiving complete clinical documentation, though standard processing can take 5-7 business days via fax.

Q: What if Skyrizi isn't on my Humana formulary? A: You can request a formulary exception by demonstrating medical necessity and that formulary alternatives would be less effective or cause adverse effects.

Q: Can I get expedited approval for urgent situations? A: Yes, contact 1-800-555-CLIN to request expedited review if there's immediate medical need.

Q: What happens if I fill Skyrizi without prior authorization? A: You'll likely be responsible for the full cost, which can be several thousand dollars per dose.

Q: Does step therapy apply if I've tried other biologics outside New York? A: Yes, prior treatment history from any location typically counts toward step therapy requirements if properly documented.

Q: How do I track my prior authorization status? A: Use your MyHumana online account or call the number on your insurance card for real-time updates.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult with your healthcare provider and insurance plan directly for guidance specific to your situation. For additional help with insurance appeals in New York, contact Community Health Advocates at 888-614-5400.

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