By Counterforce Health Team in Skyrizi (risankizumab) —

If Skyrizi (Risankizumab) Isn't Approved by Cigna in Georgia: Formulary Alternatives & Exception Paths

Answer Box: When Cigna Denies Skyrizi (Risankizumab) in Georgia

If Cigna denies Skyrizi (risankizumab) coverage in Georgia, you have three main paths: 1) Try formulary alternatives like Tremfya or Cosentyx that may be preferred, 2) Request a formulary exception with clinical documentation showing medical necessity, or 3) Appeal the denial through Cigna's internal process, then Georgia's external review if needed. Start today: Call Cigna at 1-800-882-4462 to confirm formulary status and request a peer-to-peer review. Georgia residents have 60 days from final denial to file external review with the Georgia Department of Insurance.

Table of Contents

When Formulary Alternatives Make Sense

Before pursuing a lengthy appeal process, consider whether Cigna's preferred alternatives might work for your condition. This approach can get you started on treatment weeks or months faster.

Alternatives are appropriate when:

  • You haven't tried TNF inhibitors or IL-17 inhibitors yet
  • Your condition is stable enough to allow a trial period
  • You don't have contraindications to preferred agents
  • Cost is a significant concern (preferred drugs often have lower copays)

Skip alternatives and go straight to exception requests when:

  • You've already failed multiple biologics in the required classes
  • You have documented contraindications to step therapy options
  • Your condition is rapidly progressing and requires immediate intervention
  • Previous adverse reactions make alternatives unsafe
Note: Cigna typically requires documented failure of at least one TNF inhibitor (like Humira or Enbrel) and often one IL-17 inhibitor (like Cosentyx) before approving IL-23 inhibitors like Skyrizi.

Typical Cigna-Preferred Alternatives to Skyrizi

Based on Cigna's step therapy requirements, here are the alternatives you'll likely be asked to try first:

For Psoriasis and Psoriatic Arthritis

TNF Inhibitors (Usually Required First):

  • Humira (adalimumab) - Most commonly preferred; weekly injections
  • Enbrel (etanercept) - Twice weekly injections
  • Cimzia (certolizumab pegol) - Every other week injections
  • Remicade (infliximab) - IV infusions every 8 weeks

IL-17 Inhibitors (Second-Line Options):

  • Cosentyx (secukinumab) - Monthly injections after loading
  • Taltz (ixekizumab) - Monthly injections after loading
  • Siliq (brodalumab) - Every other week injections

IL-12/23 Inhibitors:

  • Stelara (ustekinumab) - Every 12 weeks after loading

IL-23 Inhibitors (Closest to Skyrizi):

  • Tremfya (guselkumab) - Every 8 weeks after loading; often preferred over Skyrizi

For Crohn's Disease and Ulcerative Colitis

TNF Inhibitors:

  • Humira (adalimumab) - Every other week injections
  • Remicade (infliximab) - IV infusions every 8 weeks

Other Preferred Options:

  • Stelara (ustekinumab) - Every 8 weeks after IV induction
  • Entyvio (vedolizumab) - IV infusions every 8 weeks
  • Rinvoq (upadacitinib) - Daily oral JAK inhibitor

Pros and Cons of Alternative Biologics

Medication Pros Cons Access Considerations
Tremfya Same IL-23 mechanism as Skyrizi; 8-week dosing May still require step therapy Often preferred over Skyrizi by insurers
Cosentyx Strong psoriasis efficacy; established safety profile Higher infection risk; twice-weekly loading Usually requires TNF failure first
Humira Extensive data; multiple indications Weekly injections; immunogenicity risk Often first-line preferred
Stelara Good for psoriasis and IBD; 12-week dosing IV induction for IBD; expensive May require prior conventional therapy
Rinvoq Oral option; rapid onset Black box warnings; monitoring required Step therapy through TNFs usually required
From our advocates: "We've seen patients get Tremfya approved within days when Skyrizi was denied, simply because it was higher on Cigna's formulary tier. The clinical difference was minimal, but the access difference was huge. Sometimes the fastest path to effective treatment isn't fighting for your first choice."

Exception Strategy: When to Request Skyrizi

Medical Necessity Criteria

To get Skyrizi approved despite step therapy requirements, your provider needs to document:

Disease Severity:

  • PASI ≥10 or BSA ≥10% for psoriasis
  • Active joint involvement for psoriatic arthritis
  • Moderate to severe IBD with objective evidence

Prior Treatment Failures:

  • Specific medications tried, doses, duration, and reason for discontinuation
  • Documented lack of efficacy or adverse reactions
  • Contraindications to preferred alternatives

Clinical Rationale:

  • Why Skyrizi is specifically needed over alternatives
  • Risk of disease progression without treatment
  • Impact on quality of life and function

Required Documentation

Your provider should submit:

  • Complete treatment history with pharmacy records
  • Clinical photos showing disease severity
  • Laboratory results (inflammatory markers, disease activity scores)
  • Specialist consultation notes
  • Medical necessity letter template

Switching Logistics with Your Provider

Before Starting an Alternative

Coordinate with your care team:

  1. Review your insurance formulary to confirm coverage of the proposed alternative
  2. Schedule baseline assessments (TB screening, hepatitis panel, CBC, liver function)
  3. Discuss washout periods if switching from another biologic
  4. Arrange specialty pharmacy enrollment for medication delivery

Timeline considerations:

  • Most biologics require 3-month trials before insurers consider them "failed"
  • Allow 2-4 weeks for prior authorization processing
  • Factor in loading dose schedules for new medications

Monitoring During Alternative Therapy

Track objective measures to document response:

  • Psoriasis: PASI scores, BSA measurements, clinical photos
  • Psoriatic Arthritis: Joint counts, pain scores, functional assessments
  • IBD: Symptom diaries, inflammatory markers, endoscopic findings when appropriate
Tip: Keep detailed records of your response to alternatives. This documentation becomes crucial if you need to appeal for Skyrizi later.

Re-trying for Skyrizi Later

When to Resubmit

You can request Skyrizi again after:

  • Documented failure of required step therapy (typically 3-6 months)
  • Development of contraindications to alternatives
  • Significant change in disease severity or presentation
  • New clinical evidence supporting Skyrizi's use

Strengthening Your Case

For a successful resubmission:

  1. Document objective treatment failure with specific measures
  2. Include comparative effectiveness data showing why Skyrizi is preferred
  3. Cite updated clinical guidelines supporting IL-23 inhibition
  4. Provide specialist recommendations with detailed rationale

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. The platform analyzes denial letters and plan policies to identify specific coverage criteria, then drafts point-by-point rebuttals using FDA labeling, peer-reviewed studies, and recognized drug compendia to support medical necessity arguments.

Appeals Playbook for Georgia

Internal Appeal Process

Timeline: 180 days from denial date to file Contact: 1-800-882-4462 or via Cigna member portal

Required documents:

  • Original denial letter
  • Medical necessity letter from prescriber
  • Clinical notes and treatment history
  • Supporting literature or guidelines

External Review in Georgia

If internal appeals fail, Georgia residents can request external review:

Deadline: 60 days from final internal denial Cost: Free to consumers Contact: Georgia Department of Insurance at 1-800-656-2298

Process:

  1. Submit external review application to Georgia DOI
  2. Independent physicians review your case
  3. Decision rendered within 30 business days (72 hours for urgent cases)
  4. Cigna must comply with favorable decisions
Important: Georgia allows concurrent external review with expedited internal appeals for urgent medical situations.

Common Denial Reasons & Fixes

Denial Reason How to Overturn Required Documentation
Step therapy not met Document prior biologic failures Pharmacy records, treatment dates, reasons for discontinuation
Insufficient severity Provide objective disease measures PASI scores ≥10, clinical photos, specialist assessment
Not medically necessary Submit clinical rationale Specialist letter, guideline citations, comparative effectiveness data
Experimental/investigational Cite FDA approval FDA label, clinical study references

FAQ

How long does Cigna prior authorization take in Georgia? Standard reviews take 1-5 business days. Urgent requests are processed within 24-72 hours with proper documentation.

What if Skyrizi is non-formulary on my plan? Request a formulary exception with clinical justification. Provide evidence that formulary alternatives are inappropriate for your condition.

Can I request an expedited appeal? Yes, if delay poses serious risk to your health. Georgia allows expedited internal appeals (72 hours) and urgent external review.

Does step therapy apply if I failed biologics in another state? Yes, but ensure complete pharmacy and medical records are transferred to document prior treatment history.

How much does Skyrizi cost without insurance? List price exceeds $20,000 annually. Check AbbVie's patient assistance programs for copay cards and foundation grants.

What counts as "treatment failure" for step therapy? Lack of efficacy after adequate trial (usually 3-6 months), intolerable side effects, or contraindications to the medication.

When navigating Cigna's formulary requirements in Georgia, remember that Counterforce Health can help streamline the appeals process by analyzing your specific denial reasons and crafting evidence-based responses that align with Cigna's coverage policies.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider about treatment decisions. Coverage policies may vary by specific plan. For assistance with insurance appeals in Georgia, contact the Georgia Department of Insurance Consumer Services at 1-800-656-2298.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.