By Counterforce Health Team in Skyrizi (risankizumab) —

How to Get Skyrizi (Risankizumab) Covered by UnitedHealthcare in Virginia: Complete Guide to Prior Authorization, Appeals, and State Protections

Answer Box: Getting Skyrizi Covered by UnitedHealthcare in Virginia

UnitedHealthcare requires prior authorization for Skyrizi (risankizumab) in Virginia with mandatory step therapy—you must try and fail at least one TNF inhibitor first. Submit your PA request through the UHC Provider Portal or call OptumRx at 1-800-711-4555. Include documentation of TNF inhibitor failure, tuberculosis screening results, and clinical notes showing disease severity. If denied, Virginia law provides step therapy override protections and external review through the State Corporation Commission within 120 days.

First step today: Have your doctor gather records of any prior biologic failures and complete TB screening if not already done.

Table of Contents

  1. Why Virginia State Rules Matter
  2. UnitedHealthcare Prior Authorization Requirements
  3. Step Therapy Protections in Virginia
  4. Turnaround Standards and Timelines
  5. Common Denial Reasons & How to Fix Them
  6. Appeals Process: Internal and External Review
  7. Continuity of Care Protections
  8. Quick Reference: Forms and Contacts
  9. Frequently Asked Questions

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all plans UHC Provider Portal UHC PA Guidelines
Step Therapy Must fail ≥1 TNF inhibitor Clinical documentation OptumRx PA Guidelines
TB Screening Required before starting PPD or IGRA test results FDA Label Requirements
Appeal Deadline 180 days from denial Denial letter UHC Member Rights
External Review 120 days via SCC Form 216-A Virginia SCC

Why Virginia State Rules Matter

Virginia's insurance laws provide critical protections that work alongside UnitedHealthcare's policies. Unlike self-funded employer plans governed by federal ERISA law, Virginia-regulated commercial plans must follow state requirements for step therapy exceptions, appeal timelines, and external review processes.

Key Virginia protections include:

  • Step therapy override rights under Virginia Code § 38.2-3407.9:05
  • 72-hour response requirement for step therapy exception requests
  • External review process through the State Corporation Commission
  • Managed Care Ombudsman assistance for dispute resolution
Note: If your UnitedHealthcare plan is self-funded through your employer, these state protections may not apply. Check your Summary of Benefits and Coverage or call member services to confirm.

UnitedHealthcare Prior Authorization Requirements

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage - Call UnitedHealthcare member services to confirm Skyrizi is on your formulary and what tier it's placed on.
  2. Complete TB Screening - Your doctor must order either a tuberculin skin test (TST) or interferon-gamma release assay (IGRA) like QuantiFERON-Gold before starting Skyrizi.
  3. Document TNF Inhibitor Trial - Gather records showing you tried and failed at least one TNF inhibitor (Humira, Enbrel, Cimzia, etc.) with specific dates, doses, and reasons for discontinuation.
  4. Submit PA Request - Your provider submits through the UHC Provider Portal or calls OptumRx at 1-800-711-4555.
  5. Include Required Documentation:
    • Clinical notes showing disease severity
    • Prior therapy failure documentation
    • TB screening results
    • Diagnosis codes (ICD-10)
    • Prescriber attestation
  6. Track Your Request - Standard PA decisions take up to 15 business days; urgent requests within 72 hours.
  7. Prepare for Potential Denial - Have your appeal strategy ready with additional clinical evidence.

Medical Necessity Criteria

UnitedHealthcare typically requires documentation of:

  • Diagnosis confirmation with appropriate ICD-10 codes
  • Disease severity meeting treatment thresholds
  • Prior conventional therapy failure (methotrexate, phototherapy for psoriasis)
  • TNF inhibitor trial and failure with specific details
  • Contraindications to required step therapy drugs
  • Provider attestation of medical necessity

Step Therapy Protections in Virginia

Virginia law (§ 38.2-3407.9:05) requires UnitedHealthcare to grant step therapy exceptions when specific criteria are met. This is crucial for Skyrizi approval since most plans require TNF inhibitor failure first.

Exception Criteria (Must Grant If Documented)

  1. Contraindication - The required step therapy drug is medically inappropriate
  2. Ineffectiveness - Based on patient characteristics, the required drug won't work
  3. Prior failure or intolerance - Patient previously tried the required drug and it failed or caused adverse effects
  4. Stability on current therapy - Patient is doing well on the prescribed medication

How to Request an Exception

Your prescriber should submit a step therapy exception request including:

  • Reference to Virginia Code § 38.2-3407.9:05
  • Specific criterion being met (contraindication, prior failure, etc.)
  • Detailed clinical documentation supporting the exception
  • Timeline notation if urgent care is needed
From our advocates: We've seen patients succeed by having their rheumatologist write a detailed letter explaining why the patient's specific psoriatic arthritis presentation makes TNF inhibitors inappropriate, referencing both the Virginia statute and clinical guidelines. The key is being specific about why standard step therapy won't work for this individual patient.

Turnaround Standards and Timelines

Virginia Requirements

  • Step therapy exceptions: 72 hours for standard requests, 24 hours for urgent
  • Prior authorization: 15 business days standard, 72 hours urgent
  • Appeals: UnitedHealthcare must acknowledge within 5 business days

UnitedHealthcare Internal Process

  • Standard PA: Up to 15 business days
  • Expedited PA: 72 hours when medical urgency documented
  • Appeals: 60 days for standard, 72 hours for expedited
  • External review eligibility: After exhausting internal appeals

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Documentation Needed
Missing TNF inhibitor trial Submit step therapy exception Virginia statute reference + clinical rationale
Incomplete TB screening Provide test results PPD or IGRA results with interpretation
Insufficient disease severity Submit additional clinical evidence PASI scores, joint counts, endoscopy reports
Non-formulary status Request formulary exception Medical necessity letter citing alternatives tried
Quantity limits exceeded Justify dosing requirements Clinical notes explaining weight-based dosing

Appeals Process: Internal and External Review

Internal Appeals with UnitedHealthcare

First Level Appeal:

  • Deadline: 180 days from denial notice
  • Submission: UHC Provider Portal, fax, or mail
  • Timeline: 60 days for decision (72 hours if expedited)
  • Required: Original denial letter, additional clinical evidence, provider letter

Second Level Appeal:

  • Automatic: If first level denied
  • Timeline: Additional 60 days
  • Review: Different clinical reviewer than first level

Virginia External Review Process

After exhausting UnitedHealthcare's internal appeals, Virginia residents can request external review through the State Corporation Commission.

Key Requirements:

Required Documents:

  • Completed Form 216-A
  • Final denial letter from UnitedHealthcare
  • Medical records and clinical notes
  • Summary statement of your case
  • Insurance card copy
Tip: Contact the Virginia Managed Care Ombudsman at 1-877-310-6560 before filing external review. They can guide you through the process and ensure you include all necessary documentation.

Continuity of Care Protections

Transitions Between Plans

If you're switching from another insurer to UnitedHealthcare while stable on Skyrizi, Virginia law provides some continuity protections:

  • Ongoing therapy: May qualify for temporary coverage during PA review
  • Grace period: Some plans provide 30-day supply while reviewing
  • Provider network: Ensure your prescribing doctor is in-network

Renewal Requirements

UnitedHealthcare typically requires annual reauthorization for Skyrizi with documentation of:

  • Continued medical necessity
  • Positive clinical response
  • Absence of significant adverse effects
  • Updated lab results if required for your indication

Quick Reference: Forms and Contacts

UnitedHealthcare Contacts

  • OptumRx PA Line: 1-800-711-4555
  • Provider Portal: UHCProvider.com
  • Member Services: Number on your insurance card
  • Appeals Fax: Check your denial letter for plan-specific number

Virginia State Resources

  • SCC Bureau of Insurance: 1-877-310-6560
  • External Review Email: [email protected]
  • Managed Care Ombudsman: 1-877-310-6560
  • Consumer Complaint Portal: Virginia SCC

Essential Forms

  • Form 216-A: External Review Request
  • Form 216-B: Authorized Representative (if filing for someone else)
  • Form 216-C: Expedited Review Request

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Virginia? Standard PA requests take up to 15 business days. Urgent requests with medical necessity documentation are processed within 72 hours.

What if Skyrizi isn't on my formulary? Request a formulary exception through your provider. Include medical necessity documentation and evidence that formulary alternatives aren't appropriate.

Can I request an expedited appeal? Yes, if your doctor certifies that waiting for standard review could seriously harm your health. Virginia requires 72-hour decisions for expedited external reviews.

Does step therapy apply if I failed TNF inhibitors with a previous insurer? Yes, document prior failures from any insurer. Virginia step therapy protections apply regardless of where the prior therapy occurred.

What happens if external review overturns the denial? UnitedHealthcare must authorize coverage within 24 hours for expedited cases, or 1-3 days for standard cases, per Virginia law.

Are self-funded employer plans subject to Virginia protections? Generally no, but some Virginia-based employers opt into state protections. Check your Summary Plan Description or ask HR.

How much does Skyrizi cost without insurance? List price is approximately $20,000+ per year. AbbVie offers patient assistance programs—visit Skyrizi Complete for eligibility information.

Can I appeal while starting treatment? Some plans offer temporary coverage during appeals. Ask about bridge therapy or samples from your provider while the appeal is pending.

Counterforce Health specializes in turning insurance denials into successful appeals by analyzing denial letters, payer policies, and clinical documentation to create targeted, evidence-backed rebuttal letters. Our platform helps patients, clinicians, and specialty pharmacies navigate complex prior authorization requirements and appeal processes more effectively. Learn more about our services at www.counterforcehealth.org.

For complex cases involving multiple denials or urgent medical situations, consider working with healthcare advocates or organizations like Counterforce Health that specialize in insurance appeals and can help craft compelling medical necessity arguments tailored to specific payer requirements.

Sources & Further Reading

This article is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider about treatment decisions and contact Virginia insurance regulators or qualified advocates for specific appeal guidance. Information is current as of publication date and subject to change based on policy updates.

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