By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (Risankizumab) Covered by UnitedHealthcare in New Jersey: Prior Authorization Guide with Appeals Process

Answer Box: Getting Skyrizi Covered by UnitedHealthcare in New Jersey

Quick Path to Approval: Skyrizi (risankizumab) requires prior authorization from UnitedHealthcare. You'll need documented failure of topical treatments (for psoriasis) or TNF inhibitors like Humira (for psoriatic arthritis/IBD), plus tuberculosis screening. If denied, New Jersey's Independent Health Care Appeals Program (IHCAP) offers external review within 180 days. First step today: Have your doctor submit the UnitedHealthcare Skyrizi prior authorization form with complete treatment history and clinical justification.

Table of Contents

  1. When Alternatives Make Sense
  2. Typical Formulary Alternatives
  3. Pros and Cons Overview
  4. Exception Strategy
  5. Switching Logistics
  6. Re-trying for Skyrizi Later
  7. Step-by-Step: Fastest Path to Approval
  8. Appeals Playbook for New Jersey
  9. Common Denial Reasons & Fixes
  10. FAQ

When Alternatives Make Sense

Sometimes trying UnitedHealthcare's preferred alternatives first can actually get you faster access to effective treatment. This makes sense when:

  • Step therapy is required anyway - UnitedHealthcare typically requires failure of preferred biologics before approving Skyrizi for psoriatic arthritis and IBD
  • Your condition isn't severe enough yet - For psoriasis, you need at least 3% body surface area involvement or involvement of sensitive areas (palms, soles, face, genitals)
  • TB screening is incomplete - All biologics require tuberculosis screening, but some alternatives may have less stringent monitoring requirements
  • Cost considerations - Preferred alternatives often have lower copays and fewer prior authorization hurdles

However, don't delay necessary treatment. If you've already failed multiple therapies or have contraindications to alternatives, push for Skyrizi approval directly.

Typical Formulary Alternatives

Based on UnitedHealthcare's current formulary, here are the preferred alternatives by condition:

For Plaque Psoriasis

  • Cosentyx (secukinumab) - IL-17A inhibitor, preferred status
  • Stelara (ustekinumab) - IL-12/23 inhibitor, similar mechanism to Skyrizi
  • Sotyktu (deucravacitinib) - Oral TYK2 inhibitor, newer preferred option
  • Tremfya (guselkumab) - IL-23 inhibitor, very similar to Skyrizi

For Psoriatic Arthritis

  • Enbrel (etanercept) - TNF inhibitor, often required first-line
  • Cosentyx (secukinumab) - IL-17A inhibitor with joint and skin benefits
  • Tremfya - Available as step therapy option

For IBD (Crohn's/Ulcerative Colitis)

  • Humira (adalimumab) - TNF inhibitor, typically required first
  • Cimzia (certolizumab) - Alternative TNF inhibitor
  • Rinvoq (upadacitinib) - JAK inhibitor for moderate-severe cases

Pros and Cons Overview

Medication Class Access Benefits Testing Requirements Monitoring Needs
TNF Inhibitors (Humira, Enbrel) Lower copays, fewer PA hurdles TB screening, Hepatitis B/C Regular CBC, liver function tests
IL-17 Inhibitors (Cosentyx) Good for psoriasis + arthritis TB screening Less intensive monitoring
IL-23 Inhibitors (Tremfya, Stelara) Similar efficacy to Skyrizi TB screening Minimal ongoing monitoring
JAK Inhibitors (Rinvoq) Oral option for IBD Extensive lab screening Regular blood work, lipid monitoring
From our advocates: We've seen patients successfully transition from Tremfya to Skyrizi after documenting inadequate joint response in psoriatic arthritis cases. The similar mechanisms made the switch easier to justify, and UnitedHealthcare approved it as a "therapeutic substitution" rather than requiring full step therapy reset.

Exception Strategy

Request a Skyrizi exception when alternatives aren't appropriate due to:

Strong Clinical Reasons

  • Contraindications - Document specific medical reasons why preferred alternatives can't be used (heart failure for TNF inhibitors, active infections, etc.)
  • Previous failures - Detailed records of inadequate response or intolerance to preferred options
  • Urgent medical need - Rapidly progressing disease requiring immediate treatment

Documentation That Helps

According to UnitedHealthcare's exception criteria, include:

  • Complete treatment history with dates, doses, and outcomes
  • Objective disease severity measures (PASI scores, endoscopy results, joint counts)
  • FDA MedWatch forms for documented adverse reactions
  • Supporting literature for off-label uses
  • Peer-reviewed studies supporting medical necessity

Switching Logistics

When transitioning between biologics, coordination prevents gaps in coverage and ensures safety:

Provider Coordination

  • Washout period - Wait 2 weeks after stopping TNF inhibitors before starting Skyrizi
  • Infection screening - Update TB testing and check for active infections
  • Documentation - Record clinical rationale for switching in medical notes

Pharmacy Logistics

  • Submit prior authorization before stopping current therapy
  • Coordinate specialty pharmacy delivery with washout timeline
  • Ensure patient education on new injection schedule
  • Never overlap biologic therapies - this raises safety concerns and insurance red flags

Counterforce Health helps streamline this process by automatically generating targeted appeal letters that address UnitedHealthcare's specific denial reasons and include the right clinical evidence for biologic switches.

Re-trying for Skyrizi Later

If you start with an alternative, document everything for a future Skyrizi request:

What to Track

  • Response measures - Use validated scales (PASI, DAS28, CDAI scores)
  • Side effects - Record any adverse reactions with dates and severity
  • Adherence issues - Note injection site reactions, convenience problems
  • Quality of life impact - Document functional limitations

When to Switch

  • After 3-6 months if inadequate response (less than 50% improvement)
  • Immediately if serious adverse reactions occur
  • When disease progression continues despite treatment

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage Requirements (Patient/Clinic)
    • Check your specific UnitedHealthcare formulary tier
    • Confirm prior authorization is required
    • Timeline: Same day
  2. Gather Documentation (Clinic)
    • Treatment history for past 12 months
    • Lab results, imaging, severity scores
    • Timeline: 1-2 business days
  3. Complete TB Screening (Patient)
    • Chest X-ray, tuberculin skin test or QuantiFERON
    • Timeline: 3-5 business days for results
  4. Submit Prior Authorization (Clinic)
  5. Await Decision (Patient/Clinic)
    • Standard review: 15 business days
    • Expedited review: 72 hours if urgent
    • Timeline: Per UnitedHealthcare policy
  6. Appeal if Denied (Patient/Clinic)
    • Internal appeal within 180 days
    • Include additional documentation addressing denial reasons
    • Timeline: 30 days for standard, 72 hours for expedited
  7. External Review if Needed (Patient)
    • File with New Jersey IHCAP within 180 days of final denial
    • Timeline: 45 days for decision

Appeals Playbook for New Jersey

New Jersey offers strong consumer protections through the Independent Health Care Appeals Program (IHCAP).

Internal Appeals (UnitedHealthcare)

  • Deadline: 180 days from denial notice
  • Levels: Two internal review levels required
  • Submission: UnitedHealthcare member portal, fax, or mail
  • Timeline: 30 days standard, 72 hours expedited

External Review (IHCAP)

  • Eligibility: After completing internal appeals
  • Deadline: 180 days from final internal denial
  • Process: Submit directly to Maximus Federal Services (contracted by NJ)
  • Cost: Free to patients
  • Timeline: 45 days standard, expedited available for urgent cases
  • Success Rate: Approximately 50% of external appeals favor consumers
Tip: New Jersey's IHCAP decisions are binding on insurers. If the independent medical reviewers determine Skyrizi is medically necessary, UnitedHealthcare must cover it.

For help with the appeals process, contact:

  • IHCAP Hotline: 1-888-393-1062
  • NJ Consumer Hotline: 1-800-446-7467

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documentation
Step therapy not met Document failure/contraindication of preferred alternatives Treatment history with dates, outcomes, adverse reactions
Insufficient severity Provide objective disease measures PASI scores >10, BSA >3%, or sensitive area involvement
Missing TB screening Complete required testing Chest X-ray, TST/QuantiFERON results within 6 months
Not medically necessary Submit comprehensive medical necessity letter Clinical guidelines, peer-reviewed literature, treatment goals
Quantity limits exceeded Justify dosing based on FDA labeling Weight-based calculations, treatment response data

FAQ

How long does UnitedHealthcare prior authorization take in New Jersey? Standard review takes up to 15 business days. Expedited review (for urgent cases) takes 72 hours. You can check status through the UnitedHealthcare provider or member portal.

What if Skyrizi is non-formulary on my plan? Non-formulary medications require additional documentation but can still be approved. You'll need stronger medical necessity justification and may face higher copays even if approved.

Can I request an expedited appeal in New Jersey? Yes, if a delay would cause serious harm to your health. Both UnitedHealthcare internal appeals and New Jersey external reviews offer expedited timelines for urgent cases.

Does step therapy apply if I failed treatments outside New Jersey? Yes, treatment failures from other states count toward step therapy requirements. Ensure your new provider has complete medical records from previous doctors.

What copay assistance is available for Skyrizi? AbbVie offers the Skyrizi Complete Savings Program with potential $5 copays for eligible patients with commercial insurance.

How do I file a complaint against UnitedHealthcare in New Jersey? Contact the NJ Department of Banking and Insurance Consumer Hotline at 1-800-446-7467 or file online complaints for coverage disputes.

When Coverage Gets Complicated

Complex cases benefit from specialized support. Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters, identifies specific coverage gaps, and drafts point-by-point rebuttals aligned to UnitedHealthcare's own policies—saving time and improving approval rates for challenging biologic cases.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions.

Sources & Further Reading

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