By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (Risankizumab) Covered by Humana in North Carolina: Decision Tree & Appeals Guide

Quick Answer: Humana Medicare Advantage requires prior authorization for Skyrizi (risankizumab) with documented TNF inhibitor failure for psoriasis, or CDAI scores for Crohn's disease. Submit via Humana provider portal with clinical notes showing severity (PASI ≥10, BSA ≥10%). If denied, you have 65 days to appeal internally, then escalate to federal Medicare review. North Carolina's Smart NC external review doesn't apply to Medicare plans. First step today: Gather your diagnosis documentation, prior therapy records, and TB screening results.

Table of Contents

  1. How to Use This Decision Tree
  2. Eligibility Triage: Do You Qualify?
  3. If You're Likely Eligible
  4. If You're Possibly Eligible
  5. If You're Not Yet Eligible
  6. If Your Request Gets Denied
  7. Coverage Requirements at a Glance
  8. Appeals Process for North Carolina
  9. Common Denial Reasons & How to Fix Them
  10. FAQ

How to Use This Decision Tree

This guide helps patients and clinicians navigate Skyrizi (risankizumab) coverage through Humana Medicare Advantage plans in North Carolina. Start with the eligibility triage below to understand your approval chances, then follow the appropriate pathway.

Important: Humana Medicare Advantage plans follow federal Medicare appeals rules, not North Carolina's Smart NC external review process. Commercial Humana plans do qualify for Smart NC review.

Eligibility Triage: Do You Qualify?

Step 1: Confirm Your Diagnosis

You need one of these FDA-approved conditions:

  • Moderate-to-severe plaque psoriasis (adults)
  • Active psoriatic arthritis (adults)
  • Moderately to severely active Crohn's disease (adults)
  • Moderately to severely active ulcerative colitis (adults)

Step 2: Check Severity Requirements

For Plaque Psoriasis:

  • PASI score ≥10-12 (varies by plan)
  • Body Surface Area (BSA) ≥10%
  • Eligible for systemic therapy or phototherapy

For Psoriatic Arthritis:

  • Active joint involvement (documented tender/swollen joints)
  • Inadequate response to conventional DMARDs

For Crohn's Disease:

  • CDAI score documenting moderate-severe activity
  • Endoscopic evidence of inflammation (SES-CD scores)
  • Prior conventional therapy inadequacy

Step 3: Prior Therapy Requirements

Humana typically requires documented failure of:

  • Psoriasis: At least one TNF inhibitor (etanercept, adalimumab, infliximab) for 3-6 months
  • Psoriatic Arthritis: Non-biologic DMARD (like methotrexate) or biologic DMARD
  • Crohn's Disease: Conventional therapy (corticosteroids, immunosuppressants) or biologics

Step 4: Required Testing

  • TB screening: QuantiFERON test or TB skin test within 12 months
  • Chest X-ray if TB test positive
  • Hepatitis B screening (HBsAg, anti-HBc, anti-HBs)
  • Baseline liver function tests

If You're Likely Eligible

You meet all criteria above. Here's your fastest path to approval:

Document Checklist

  • Current diagnosis with ICD-10 codes
  • PASI/BSA scores (psoriasis) or CDAI scores (Crohn's)
  • Prior therapy failure documentation with dates, doses, duration
  • Negative TB screening within 12 months
  • Hepatitis B screening results
  • Recent clinical notes (within 3-6 months)

Submission Process

  1. Provider submits via Humana Prior Authorization Search Tool
  2. Timeline: 95% of electronic requests decided within 1 business day
  3. Required forms: Use Humana-specific PA form from provider portal
  4. Include: Medical necessity letter with clinical rationale
Tip: Request expedited review if treatment delay would jeopardize your health. Decisions come within 72 hours for urgent cases.

If You're Possibly Eligible

You have the diagnosis but missing some requirements. Here's what to track:

Tests to Request

  • Severity documentation: Ask your doctor to calculate and document PASI/BSA scores or CDAI scores
  • TB screening: Get QuantiFERON or TB skin test if older than 12 months
  • Prior therapy records: Gather documentation from previous treatments showing inadequate response

Timeline to Re-apply

  • TB testing: Results typically available within 1-3 business days
  • Severity scoring: Can be done at your next appointment
  • Prior therapy documentation: May take 1-2 weeks to obtain records from previous providers

If You're Not Yet Eligible

Missing key requirements like prior therapy failure. Here are your options:

Alternatives to Discuss

  • Step therapy compliance: Complete required prior treatments (TNF inhibitors for psoriasis, DMARDs for psoriatic arthritis)
  • Clinical trial enrollment: May provide access while building documentation
  • Manufacturer assistance: Skyrizi Complete program offers patient support

Exception Requests

  • Medical contraindications: Document why required prior therapies can't be used
  • Prior authorization override: Submit compelling medical necessity with specialist support
  • Formulary exception: If Skyrizi is non-formulary on your specific plan

If Your Request Gets Denied

First-Level Internal Appeal

  • Deadline: 65 days from denial notice
  • How to submit: Humana member portal or mail to address on denial letter
  • Include: Denial copy, additional clinical evidence, medical necessity letter
  • Timeline: 30 days for standard decisions, 72 hours for expedited

Federal Medicare Appeals

Since North Carolina's Smart NC external review doesn't apply to Medicare Advantage plans, you'll follow the federal Medicare appeals process:

  1. Level 2: Independent Review Entity (IRE) - MAXIMUS Federal
  2. Level 3: Administrative Law Judge hearing
  3. Level 4: Medicare Appeals Council
  4. Level 5: Federal District Court
Note: Each level has specific deadlines and dollar thresholds. Contact 1-800-MEDICARE for guidance.

Coverage Requirements at a Glance

Requirement Psoriasis Psoriatic Arthritis Crohn's Disease Source
Prior Authorization Required Required Required Humana Policy
Step Therapy TNF inhibitor failure DMARD failure Conventional therapy failure Humana PA Lists
Severity Criteria PASI ≥10, BSA ≥10% Active joint involvement CDAI scores FDA Label
TB Screening Required within 12 months Required within 12 months Required within 12 months FDA Label
Specialty Pharmacy Yes Yes Yes Verify with plan

Appeals Process for North Carolina

Internal Appeals (All Humana Plans)

  • Medicare Advantage: 65 days to file, 30-day decision timeline
  • Commercial Plans: 180 days to file, varies by plan
  • Expedited: 72 hours if health at risk

External Review Options

  • Medicare Advantage: Federal IRE process only
  • Commercial Plans: North Carolina Smart NC external review
    • 120 days to file after internal denial
    • 45 days for standard review, 72 hours for expedited
    • Contact: 1-855-408-1212

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documents
Insufficient severity Submit updated PASI/BSA or CDAI scores Recent clinical assessment with scoring
Missing step therapy Document prior therapy failure or contraindications Pharmacy records, clinical notes showing inadequate response
Incomplete TB screening Provide negative TB test results QuantiFERON or TST within 12 months
Not medically necessary Strengthen clinical rationale with guidelines Specialty society guidelines, peer-reviewed studies

FAQ

How long does Humana prior authorization take for Skyrizi in North Carolina? Humana processes 95% of electronic PA requests within 1 business day. Paper submissions may take longer.

What if Skyrizi is non-formulary on my Humana plan? You can request a formulary exception with medical necessity documentation. Include clinical rationale for why formulary alternatives aren't appropriate.

Can I get an expedited appeal if my Humana claim is denied? Yes, if your physician certifies that a delay would seriously jeopardize your health. Expedited appeals are decided within 72 hours.

Does step therapy apply if I tried TNF inhibitors in another state? Yes, prior therapy documentation from any state counts toward step therapy requirements. Gather records from previous providers.

What's the difference between Medicare Advantage and commercial Humana appeals in North Carolina? Medicare Advantage follows federal appeals rules only. Commercial Humana plans can use North Carolina's Smart NC external review after internal appeals are exhausted.

How much will Skyrizi cost with Humana coverage? With Medicare Part D, you'll pay 25% coinsurance until reaching $2,000 out-of-pocket, then $0 for the rest of the year. Commercial plan costs vary by tier placement.

From our advocates: We've seen many Skyrizi approvals succeed when providers include specific PASI improvement targets and cite the drug's unique IL-23 mechanism compared to failed TNF inhibitors. Documentation showing why alternatives like Stelara or Cosentyx aren't suitable often strengthens the medical necessity case. This is a composite example based on common successful strategies, not a guarantee of outcomes.

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to draft point-by-point rebuttals aligned with payer requirements, pulling appropriate clinical evidence and operational details that reduce back-and-forth with insurers.

For additional support navigating complex prior authorization requirements, Counterforce Health provides payer-specific workflows and templates that help ensure your Skyrizi appeal meets all procedural requirements while tracking deadlines and required documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult your healthcare provider for medical decisions. Insurance coverage varies by plan and individual circumstances. For official appeals guidance, contact your insurer directly or North Carolina's Department of Insurance at 1-855-408-1212.

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