By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (Risankizumab) Covered by UnitedHealthcare in Illinois: Complete Prior Authorization Guide with Forms and Appeals

Quick Answer: Getting Skyrizi Covered by UnitedHealthcare in Illinois

UnitedHealthcare requires prior authorization for Skyrizi (risankizumab) in Illinois. The fastest path to approval: verify your diagnosis meets severity criteria, document failed topical therapies (for psoriasis) or TNF inhibitor failure (for psoriatic arthritis/IBD), complete TB screening, and submit via the UHC Provider Portal. First step today: Log into your provider portal to download the current Skyrizi PA form and check your patient's formulary tier. Standard approvals take 14-15 days; urgent cases get 24-72 hour decisions. If denied, Illinois law gives you strong appeal rights with independent external review within 30 days.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Verify Your Coverage
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up and Timeline Expectations
  6. Common Denial Reasons and How to Fix Them
  7. Appeals Process in Illinois
  8. Renewal and Re-authorization
  9. Costs and Patient Assistance
  10. Frequently Asked Questions

What This Guide Covers

This guide helps patients, caregivers, and healthcare providers navigate UnitedHealthcare's prior authorization process for Skyrizi (risankizumab) in Illinois. Skyrizi is an IL-23 inhibitor approved for moderate to severe plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis.

Who this helps:

  • Patients with UnitedHealthcare coverage (commercial, Medicare Advantage) in Illinois
  • Healthcare providers submitting PA requests
  • Caregivers managing appeals and follow-up

Expected outcomes: With proper documentation, most Skyrizi requests are approved within 14-15 days. If denied, Illinois provides robust appeal rights including independent external review.

Before You Start: Verify Your Coverage

Coverage at a Glance

Requirement Details Where to Find It Source
Prior Authorization Required for all indications UHC Provider Portal UHC PA Guidelines
Formulary Tier Typically Tier 2 specialty Member portal or formulary PDF OptumRx Formularies
Step Therapy Yes - topicals for psoriasis, TNF inhibitors for PsA/IBD PA form requirements UHC Skyrizi Policy
TB Screening Mandatory within 12 months Clinical documentation UHC Medical Necessity
Appeals Deadline 30 days for external review Illinois insurance law Illinois DOI

Plan Type Verification

  1. Check if UnitedHealthcare or OptumRx manages your pharmacy benefits
  2. Confirm in-network status of your prescribing provider
  3. Verify specialty pharmacy requirements (often required for biologics)
  4. Review your specific formulary - requirements can vary by plan
Tip: Call UnitedHealthcare member services at the number on your insurance card to confirm Skyrizi's formulary status and PA requirements for your specific plan.

Gather Required Documentation

Essential Documents Checklist

Clinical Information:

  • Primary diagnosis with ICD-10 code
  • Disease severity documentation (≥3% BSA for psoriasis, active joint symptoms for PsA)
  • Prior therapy trials and outcomes
  • TB screening results (TST or IGRA within 12 months)
  • Recent lab values and clinical notes
  • Contraindications assessment

Administrative Documents:

  • Current UnitedHealthcare Skyrizi PA form
  • Patient insurance card and ID
  • Prescriber NPI and contact information
  • Previous denial letters (if resubmitting)

Diagnosis-Specific Requirements

Plaque Psoriasis:

  • Must document failed topical therapy with at least one of: corticosteroids, vitamin D analogs (calcitriol, calcipotriene), tazarotene, calcineurin inhibitors, anthralin, or coal tar
  • Include drug name, dates, duration, and reason for discontinuation
  • Document disease severity: ≥3% body surface area OR involvement of palms, soles, face, genitals, or severe scalp disease

Psoriatic Arthritis & IBD:

  • Must show prior TNF inhibitor failure or contraindication
  • Document inadequate response, loss of response, or intolerance
  • Include specific medications tried and clinical outcomes

Submit Your Prior Authorization Request

Step-by-Step Submission Process

  1. Access the UHC Provider Portal at uhcprovider.com
  2. Download the current Skyrizi PA form (forms are updated regularly)
  3. Complete all required fields - incomplete forms cause delays
  4. Attach supporting documentation in PDF format
  5. Submit electronically for fastest processing
  6. Record your confirmation number for tracking

Clean Request Packet Checklist

  • Completed PA form with all signatures
  • Clinical notes supporting diagnosis and severity
  • Prior therapy documentation with dates and outcomes
  • TB screening results clearly documented
  • Laboratory values if relevant to condition
  • Any relevant imaging or specialist consultations
Note: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to draft point-by-point rebuttals aligned with payer requirements.

Follow-Up and Timeline Expectations

Standard Timelines in Illinois

Review Type Timeline Expedited Timeline When to Follow Up
Initial PA Decision 14-15 business days 24-72 hours Day 10 if no response
Internal Appeal 15 business days 24 hours Day 12 if no response
External Review 20 business days 72 hours Weekly status checks

Sample Follow-Up Script

"Hi, I'm calling to check the status of a Skyrizi prior authorization for [patient name], member ID [number]. The request was submitted on [date] with confirmation number [number]. Can you provide an update on the review status and expected timeline?"

Document everything: Keep records of all phone calls, reference numbers, and representative names.

Common Denial Reasons and How to Fix Them

Denial Reason Fix Strategy Required Documentation
Missing TB screening Submit negative TST/IGRA results Lab report within 12 months
Inadequate prior therapy Document specific failures Drug names, dates, outcomes, reasons for discontinuation
Not medically necessary Provide severity documentation Clinical notes, photos, quality of life measures
Step therapy not met Show contraindications or failures Detailed trial history with adverse events
Concurrent biologic use Confirm discontinuation Provider attestation of medication stop

Medical Necessity Letter Template

When submitting additional documentation, include:

  1. Patient-specific clinical rationale for Skyrizi
  2. Evidence of disease severity and impact on quality of life
  3. Prior treatment failures with specific details
  4. Guideline citations supporting Skyrizi use
  5. Monitoring plan and expected outcomes

Appeals Process in Illinois

Illinois-Specific Appeal Rights

Illinois provides stronger patient protections than many states:

  • Internal appeals: Must be decided within 15 business days
  • External review: Independent physician review within 20 business days
  • 30-day deadline to request external review (shorter than most states)
  • No cost to patients for external review process

Step-by-Step Appeals Process

  1. Internal Appeal (Level 1)
    • Submit within 180 days of denial
    • Use UHC Provider Portal or mail/fax
    • Include new clinical information if available
    • Timeline: 15 business days for decision
  2. External Review (If Internal Appeal Denied)
    • Request within 30 days of final internal denial
    • Contact Illinois Department of Insurance: (877) 527-9431
    • Independent Review Organization (IRO) conducts review
    • Decision is binding on UnitedHealthcare
Critical: Illinois' 30-day external review deadline is shorter than most states. Don't delay if your internal appeal is denied.

Illinois Resources for Help

  • Illinois Department of Insurance Consumer Helpline: (877) 527-9431
  • Illinois Attorney General Health Care Bureau: (877) 305-5145
  • Online external review request: Illinois DOI website

Renewal and Re-authorization

When to Start Renewal Process

  • Calendar reminder: Set for 30-45 days before current authorization expires
  • Typical approval period: 12 months for Skyrizi
  • Required documentation: Evidence of clinical benefit and continued medical necessity

Renewal Documentation

  • Updated clinical notes showing treatment response
  • Current disease activity assessment
  • Any changes in medical history or concurrent medications
  • Continued absence of contraindications
  • Updated TB screening if required by plan

Costs and Patient Assistance

Financial Support Options

Manufacturer Support:

  • AbbVie Complete Savings Program: May reduce copays for eligible patients
  • AbbVie Patient Assistance Foundation: For uninsured/underinsured patients
  • Visit Skyrizi.com for current programs

Additional Resources:

  • Foundation grants for specialty medications
  • State pharmaceutical assistance programs
  • Hospital charity care programs
Important: Copay assistance programs may not be available for government insurance plans (Medicare, Medicaid).

Frequently Asked Questions

How long does UnitedHealthcare PA take for Skyrizi in Illinois? Standard prior authorizations are decided within 14-15 business days. Urgent/expedited requests get decisions within 24-72 hours.

What if Skyrizi is non-formulary on my plan? Non-formulary medications can still be covered through the medical exception process. Strong clinical documentation and evidence of medical necessity are essential.

Can I request an expedited appeal in Illinois? Yes, if a delay would seriously jeopardize your health. Expedited appeals must be decided within 24 hours for internal appeals and 72 hours for external review.

Does step therapy apply if I failed treatments in another state? Yes, documented treatment failures from other states should count toward step therapy requirements. Include all relevant medical records.

What happens if UnitedHealthcare denies my external review? External review decisions by Independent Review Organizations are binding on UnitedHealthcare. If the IRO approves coverage, UnitedHealthcare must provide it.

How do I know if my provider is in-network for specialty care? Check the UnitedHealthcare provider directory online or call member services. Out-of-network providers may require additional authorization.

From Our Advocates

We've seen cases where patients initially denied for Skyrizi received approval after submitting detailed documentation of topical therapy failures with specific dates and adverse reactions. The key was showing not just that treatments were tried, but why they were inadequate or caused problems. One patient's appeal succeeded when we included photos documenting disease severity and a detailed timeline of treatment attempts over 18 months.

For complex cases involving multiple denials or unusual circumstances, Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by identifying the specific denial basis and drafting point-by-point rebuttals aligned to the plan's own rules.

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical advice. Coverage decisions depend on individual plan benefits, medical necessity, and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage determinations. For official Illinois insurance regulations and consumer rights, visit the Illinois Department of Insurance website.

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