By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (Risankizumab) Covered by Humana in Ohio: Prior Authorization, Appeals, and Formulary Alternatives

Quick Answer: Getting Skyrizi Covered by Humana in Ohio

Skyrizi (risankizumab) is covered by Humana as a Tier 5 specialty drug but requires prior authorization (PA), step therapy (TNF inhibitor failure), and quantity limits. In Ohio, you have 65 days to appeal denials internally, then 180 days for external review through the Ohio Department of Insurance. Start today: Call Humana at 1-800-HUMANA-0 to verify your plan's specific requirements, then gather documentation of prior treatment failures to submit your PA request via fax to 1-888-447-3430.

Table of Contents

  1. When Formulary Alternatives Make Sense
  2. Typical Alternatives by Drug Class
  3. Coverage Requirements at a Glance
  4. Step-by-Step: Fastest Path to Approval
  5. Common Denial Reasons & Fixes
  6. Appeals Playbook for Ohio
  7. Switching from Current Biologics
  8. Re-trying for Skyrizi Later
  9. Costs & Patient Assistance
  10. FAQ

When Formulary Alternatives Make Sense

Before pursuing a lengthy prior authorization battle, consider whether Humana's preferred alternatives might work for your condition. This isn't medical advice—discuss all options with your prescriber—but understanding the landscape can save time and reduce out-of-pocket costs.

Alternatives make sense when:

  • You're treatment-naive (haven't tried biologics before)
  • Step therapy is required anyway (you'll need to try preferred drugs first)
  • Skyrizi is non-formulary on your specific Humana plan
  • Cost is a major concern (preferred alternatives often have lower copays)

Alternatives may not work if:

  • You've already failed multiple TNF inhibitors
  • You have contraindications to preferred drugs (documented allergies, liver issues)
  • Your condition requires Skyrizi's specific mechanism (IL-23 p19 inhibition)

Typical Alternatives by Drug Class

Based on Humana's formulary alternatives list, here are commonly preferred options:

For Plaque Psoriasis

Preferred (Lower Tier) Mechanism Typical Requirements
Enbrel (etanercept) TNF inhibitor May require PA, less step therapy
Otezla (apremilast) PDE4 inhibitor Often first-line after topicals
Xeljanz (tofacitinib) JAK inhibitor Requires lab monitoring

For Psoriatic Arthritis

Preferred Option Mechanism Notes
Humira (adalimumab) or biosimilars TNF inhibitor Multiple biosimilars available
Enbrel (etanercept) TNF inhibitor Self-injection, established safety
Rinvoq (upadacitinib) JAK inhibitor Oral option, requires monitoring

For Crohn's Disease/IBD

Preferred Option Administration Coverage Notes
Infliximab (Remicade, biosimilars) IV infusion Often preferred for induction
Adalimumab biosimilars (Hadlima, Yuflyma) Subcutaneous Lower cost than originator
Vedolizumab (Entyvio) IV infusion Gut-selective, if on formulary
Note: Check your specific plan's formulary at Humana's provider tool as coverage varies by plan type and region.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Must get approval before filling Humana PA lists
Step Therapy Try TNF inhibitor first (≥3 months) Plan-specific PA criteria
Quantity Limits 2 pens per 84 days typical Formulary drug guide
Specialty Pharmacy Must use designated pharmacy Humana specialty network
Appeals Deadline 65 days from denial notice CMS Medicare appeals

Step-by-Step: Fastest Path to Approval

1. Verify Your Plan Requirements

Who does it: You or your clinic
Document needed: Member ID, plan type
How to submit: Call 1-800-HUMANA-0 or check online portal
Timeline: Same day

2. Gather Treatment History Documentation

Who does it: Your prescriber's office
Documents needed:

  • Prior therapy records (drugs, doses, duration, outcomes)
  • Labs showing disease severity (PASI scores for psoriasis, CDAI for Crohn's)
  • TB screening results (within 12 months)

Timeline: 1-3 business days

3. Complete Prior Authorization Request

Who does it: Prescriber (required signature)
Form needed: Humana General PA Form or drug-specific form
How to submit: Fax to 1-888-447-3430 or online portal
Timeline: Submit within 1 week of prescription

4. Include Medical Necessity Letter

Who does it: Prescriber
Must include:

  • Specific diagnosis with ICD-10 codes
  • Documented failures of preferred alternatives
  • Clinical rationale citing guidelines
  • Expected outcomes and monitoring plan

5. Submit and Track

Timeline: 72 hours for standard decision, 24 hours for expedited
Follow up: Call Humana if no response within timeline

6. If Denied, Appeal Immediately

Timeline: 65 days from denial notice
Next step: Internal appeal first, then external review through Ohio Department of Insurance

Common Denial Reasons & Fixes

Denial Reason How to Overturn Documents Needed
Step therapy not met Document TNF inhibitor trial ≥3 months with failure Pharmacy records, clinical notes showing inadequate response
Insufficient medical necessity Provide disease severity scores PASI >10 (psoriasis), CDAI >220 (Crohn's), joint imaging
Missing TB screening Submit recent screening results QuantiFERON or TST within 12 months
Not FDA-approved indication Cite clinical guidelines for off-label use Peer-reviewed studies, specialty society guidelines
Formulary alternative available Document contraindications or failures Allergy documentation, prior adverse events

Appeals Playbook for Ohio

Ohio residents have strong appeal rights under state law. Here's your roadmap:

Internal Appeals (First Step)

  • Deadline: 65 days from denial notice
  • How to file: Humana appeals portal or written request
  • Timeline: 30 days for standard, 72 hours for expedited
  • Required: Copy of denial letter, additional medical records

External Review (If Internal Appeal Fails)

  • Deadline: 180 days from final internal denial
  • How to file: Submit request to your health plan (they notify Ohio Department of Insurance)
  • Contact: Ohio Department of Insurance Consumer Services: 1-800-686-1526
  • Timeline: 30 days standard, 72 hours expedited
  • Outcome: Binding decision by Independent Review Organization
Ohio Advantage: Even if your insurer claims your case isn't eligible for external review, the Ohio Department of Insurance can independently determine eligibility and order a review.

Escalation Options

  • Regulatory complaint: File with Ohio Department of Insurance for procedural violations
  • Federal appeals: If self-funded employer plan (ERISA), different rules apply
  • Legal action: Consult attorney for complex cases after administrative remedies

Switching from Current Biologics

If you're currently on adalimumab (Humira), infliximab (Remicade), or etanercept (Enbrel), switching to Skyrizi requires careful coordination:

Before You Switch

  1. Don't stop your current medication until Skyrizi is approved and available
  2. Notify your prescriber immediately about the planned switch
  3. Check specialty pharmacy networks - Skyrizi may require a different pharmacy

Coordination Steps

  1. Prescriber issues new prescription (not a transfer) directed to Skyrizi-approved specialty pharmacy
  2. New pharmacy initiates transfer of insurance information and medical history
  3. Prior authorization submitted with documentation of current treatment inadequacy
  4. Insurance verification confirms coverage before first shipment

Timeline Management

  • Start process 2-3 weeks early to avoid treatment gaps
  • Coordinate with specialty pharmacy for home delivery scheduling
  • Plan for potential delays during PA review process

Re-trying for Skyrizi Later

If your initial request is denied and you try a preferred alternative, document everything for a future Skyrizi request:

What to Document During Alternative Therapy

  • Exact start date and dosing of the alternative medication
  • Objective measures of response (PASI scores, symptom tracking, lab values)
  • Side effects or tolerability issues with dates and severity
  • Functional impact (work days missed, quality of life scores)
  • Duration of adequate trial (typically 3-6 months for biologics)

When to Retry Skyrizi

  • Clear treatment failure on alternative therapy
  • New clinical evidence supporting Skyrizi for your condition
  • Plan formulary changes that improve Skyrizi's coverage
  • Significant side effects from alternative requiring discontinuation

Costs & Patient Assistance

Manufacturer Support

  • Skyrizi Complete Support: Free drug for up to 2 years while awaiting insurance approval
  • Copay assistance: Up to $5 copay for eligible patients
  • Enrollment: Visit Skyrizi patient site or call 1-866-SKYRIZI

Additional Resources

  • Ohio pharmaceutical assistance programs: Check eligibility through Ohio Department of Health
  • Foundation grants: Patient Advocate Foundation, HealthWell Foundation
  • Humana member assistance: May offer temporary coverage during appeals

FAQ

How long does Humana PA take in Ohio? Standard PA decisions: 72 hours. Expedited (if delay risks health): 24 hours with physician certification.

What if Skyrizi is non-formulary on my plan? Request a formulary exception using Humana's Medicare Part D Exception form. Must document that all formulary alternatives are ineffective or cause adverse effects.

Can I request an expedited appeal in Ohio? Yes, if delay would seriously jeopardize your health. Requires physician statement. Expedited reviews: 72 hours for external review.

Does step therapy apply if I failed biologics outside Ohio? Yes, document prior failures from any state/insurer. Humana accepts external treatment history with proper documentation.

What counts as "treatment failure" for step therapy? Inadequate response after 3+ months at optimal dosing, OR significant adverse effects requiring discontinuation, OR medical contraindication to the preferred drug.

Can my doctor request a peer-to-peer review? Yes, prescribers can request to speak directly with Humana's medical director. Often faster than written appeals for complex cases.

When navigating insurance approvals for specialty medications like Skyrizi, having expert support can make the difference between approval and denial. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with each payer's specific requirements.

The platform identifies the exact denial basis—whether PA criteria, step therapy, non-formulary status, or "not medically necessary"—and pulls the right evidence from FDA labeling, peer-reviewed studies, and specialty guidelines. For complex cases involving multiple prior treatments and appeals, this systematic approach can significantly improve approval rates while reducing the administrative burden on healthcare providers.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Coverage policies vary by plan and change frequently. Always verify current requirements with your insurer and consult your healthcare provider for medical decisions. For personalized assistance with Ohio insurance appeals, contact the Ohio Department of Insurance Consumer Services Division.

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