By Counterforce Health Team in Skyrizi (risankizumab) —

If Skyrizi Isn't Approved by Cigna in Florida: Formulary Alternatives & Exception Paths

Answer Box: Your Options When Cigna Denies Skyrizi

If Cigna denies Skyrizi (risankizumab) in Florida, you have three main paths: 1) Try a covered alternative biologic like Tremfya, Cosentyx, or adalimumab biosimilars that Cigna prefers, 2) Request a formulary exception with detailed medical necessity documentation, or 3) Appeal the denial through Florida's internal and external review process. Start today by calling Cigna at the number on your card to confirm which IL-23 or TNF inhibitors are preferred on your specific plan, then coordinate with your specialist to either switch or file an exception request.

Table of Contents

  1. When Alternatives Make Sense
  2. Typical Cigna-Preferred Alternatives
  3. Pros and Cons Overview
  4. Exception Strategy for Skyrizi
  5. Switching Logistics
  6. Re-trying for Skyrizi Later
  7. Appeals Playbook for Florida
  8. FAQ

When Alternatives Make Sense

Sometimes switching to a Cigna-preferred alternative can be faster than fighting for Skyrizi approval. Consider alternatives when:

  • You're newly diagnosed and haven't tried other biologics yet
  • Your condition is stable and you can afford a 3-4 month trial period
  • Cigna requires step therapy through specific agents before covering Skyrizi
  • Cost-sharing is significantly lower for preferred alternatives

However, alternatives may not be appropriate if you've already failed multiple biologics, have contraindications to TNF inhibitors, or need the specific dosing schedule that Skyrizi offers.

Note: According to Cigna's 2025 formulary changes, many plans are moving toward preferred biosimilars and may require trying these before approving newer IL-23 inhibitors like Skyrizi.

Typical Cigna-Preferred Alternatives

Based on Cigna's current formularies, here are the most commonly preferred alternatives by condition:

For Plaque Psoriasis & Psoriatic Arthritis

TNF-α Inhibitors (Often Required First)

  • Adalimumab biosimilars (Amjevita, Hadlima, Cyltezo) - typically preferred over brand Humira
  • Etanercept and biosimilars
  • Infliximab and biosimilars

IL-17 Inhibitors

  • Secukinumab (Cosentyx) - frequently preferred
  • Ixekizumab (Taltz) - often covered with PA

IL-23/IL-12-23 Inhibitors (Same Class as Skyrizi)

  • Guselkumab (Tremfya) - often preferred over Skyrizi
  • Ustekinumab (Stelara) and biosimilar ustekinumab-ttwe

For Crohn's Disease & Ulcerative Colitis

Common Step-Therapy Requirements

  • Adalimumab/biosimilars or infliximab/biosimilars (TNF inhibitors)
  • Vedolizumab (Entyvio) (anti-integrin)
  • Ustekinumab (Stelara/biosimilars) (IL-12/23 inhibitor)

JAK Inhibitors (with safety monitoring)

  • Tofacitinib (Xeljanz) - primarily for UC
  • Other JAK inhibitors depending on plan

Pros and Cons Overview

Alternative Class Access Pros Access Cons Clinical Considerations
TNF Inhibitors Usually preferred; lower cost-sharing May require TB screening; multiple injection options Well-established safety profile; contraindicated in some infections/malignancies
IL-17 Inhibitors Good coverage for psoriasis/PsA Less established for IBD Fast onset; injection site reactions common
Tremfya (IL-23) Often preferred over Skyrizi Still requires PA Same class as Skyrizi; q8-12 week dosing
JAK Inhibitors Oral option Strong safety PA requirements FDA boxed warnings; regular lab monitoring
Tip: Express Scripts data shows that biosimilars typically have the fastest approval times and lowest cost-sharing.

Exception Strategy for Skyrizi

If alternatives aren't appropriate, request a formulary exception with these key elements:

Required Documentation

Clinical History

  • Detailed record of each preferred alternative tried, including:
    • Drug name, dose, duration (minimum 12-16 weeks for biologics)
    • Objective response measures (PASI, BSA, Mayo score, joint counts)
    • Specific reason for failure (primary non-response, loss of response, adverse events)

Medical Necessity Letter should address:

  • Why Skyrizi's mechanism (IL-23 p19 inhibition) is specifically needed
  • Contraindications to preferred alternatives
  • Risk of disease progression without Skyrizi
  • Supporting guideline references

Submission Process

  1. Call Cigna at the number on your member card to request formulary exception forms
  2. Submit via electronic PA through EviCore by Evernorth or CoverMyMeds
  3. Include all supporting documentation in the initial submission to avoid delays

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform helps identify the specific denial reasons and drafts point-by-point rebuttals aligned to each plan's own rules, significantly improving approval rates for complex biologics like Skyrizi.

Switching Logistics

Coordination Steps

With Your Provider

  • Schedule follow-up visits at 4, 8, and 12 weeks after starting new biologic
  • Establish objective monitoring plan (PASI scores, lab work, symptom tracking)
  • Discuss washout periods if switching between biologics

With Cigna/Accredo

  • Confirm the new drug is sent to Accredo specialty pharmacy if required
  • Verify copay assistance programs are transferred
  • Set up automatic refill coordination

Safety Considerations

  • Complete required screening (TB, hepatitis B/C) before starting new biologic
  • Review vaccination status
  • Monitor for injection site reactions or systemic side effects

Timeline Expectations

  • PA approval: 2-5 business days for complete submissions
  • First shipment: 5-7 days after approval
  • Clinical response: 12-16 weeks for full assessment

Re-trying for Skyrizi Later

Document everything during your alternative trial to strengthen a future Skyrizi request:

What to Track

Objective Measures

  • Monthly PASI/BSA scores (psoriasis)
  • Joint counts and function scores (psoriatic arthritis)
  • Mayo scores and endoscopy results (IBD)
  • Laboratory markers (CRP, fecal calprotectin)

Functional Impact

  • Work days missed
  • Activity limitations
  • Sleep quality
  • Mental health impact

Treatment Response

  • Initial improvement (if any)
  • Time to loss of response
  • Dose escalations attempted
  • Adverse events with dates and severity
From our advocates: We've seen patients successfully get Skyrizi approved after documenting inadequate response to two preferred alternatives over 6-8 months. The key is maintaining detailed, objective records that clearly show why the alternatives didn't work, rather than just stating "patient didn't respond."

Appeals Playbook for Florida

Internal Appeals

Level 1 (Required First)

  • Deadline: 180 days from denial notice
  • Timeline: Cigna must decide within 30 days (72 hours if expedited)
  • Submit to: Cigna appeals department via member portal or fax

Level 2

  • Deadline: 60 days from Level 1 denial
  • Timeline: 30 days for decision

External Review (Florida)

After exhausting internal appeals, Florida residents can request external review through the Florida Department of Financial Services.

Key Details

  • Deadline: 4 months after final internal denial
  • Cost: Free to consumers
  • Timeline: Up to 45 days (72 hours if expedited)
  • Success Rate: External reviews overturn approximately 40-50% of denials statewide

How to File

  • Submit request to Florida DFS Division of Consumer Services
  • Include all denial letters, medical records, and supporting documentation
  • Call the Insurance Consumer Helpline: 1-877-MY-FL-CFO (1-877-693-5236)

When working with complex prior authorization denials, Counterforce Health's platform can help identify which specific Cigna criteria weren't met and generate targeted appeal language that addresses each point systematically.

FAQ

How long does Cigna prior authorization take in Florida? Standard PA requests typically take 72 hours once complete documentation is submitted. Expedited requests (for urgent medical needs) must be decided within 24 hours per Florida regulations.

What if Skyrizi is completely excluded from my Cigna plan? You can still request a formulary exception with strong medical necessity documentation. Focus on why all covered alternatives are inappropriate or have failed.

Can I request an expedited appeal? Yes, if delay in treatment could seriously jeopardize your health. Document the urgency and submit through Cigna's expedited appeal process.

Does step therapy apply if I failed biologics outside Florida? Yes, treatment history from other states counts. Provide complete documentation including medical records from previous providers.

What's the difference between Skyrizi and Tremfya? Both are IL-23 inhibitors with similar efficacy. Tremfya targets the p19 subunit (like Skyrizi) and is often preferred by Cigna plans. Dosing schedules differ slightly.

How do I find my specific Cigna formulary? Log into myCigna portal or call the member services number on your insurance card. Formularies vary by plan type and employer.

What if my appeal is denied at all levels? Consider consulting with a patient advocate organization or healthcare attorney. You may also file a complaint with Florida's Office of Insurance Regulation for procedural violations.

Are there patient assistance programs for alternatives? Yes, most biologic manufacturers offer copay assistance cards and patient access programs. Check the manufacturer's website or ask your specialty pharmacy.

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about treatment decisions. For official appeals processes and current formulary information, contact Cigna directly or visit the Florida Department of Financial Services website.

Need help with a complex denial? Counterforce Health helps patients and providers turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed responses. Learn more about their services.

Sources & Further Reading

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