By Counterforce Health Team in Skyrizi (risankizumab) —

Myths vs. Facts: Getting Skyrizi (Risankizumab) Covered by Humana in California

Answer Box: Skyrizi Coverage Through Humana in California

Getting Skyrizi (risankizumab) covered by Humana requires prior authorization with step therapy documentation. Most patients must show failure or intolerance to TNF inhibitors first. The fastest path: have your doctor submit complete PA documentation including TB screening, prior therapy details, and medical necessity justification through Humana's provider portal. If denied, file an internal appeal within 65 days, then escalate to California's Independent Medical Review (IMR) through the DMHC. Start today: Call Humana at 1-800-HUMANA to confirm your plan's specific requirements.

Table of Contents

Why Skyrizi Coverage Myths Persist

Misinformation about getting Skyrizi (risankizumab) covered spreads quickly among patients facing insurance hurdles. The complexity of prior authorization requirements, combined with varying policies across different Humana plans, creates confusion. Add California's unique dual-regulator system—where the Department of Managed Health Care (DMHC) oversees HMOs while the California Department of Insurance (CDI) handles other plans—and it's no wonder patients receive conflicting advice.

The stakes are high: Skyrizi can cost thousands monthly without coverage. When patients hear success stories from other states or different insurers, they often assume the same approach will work with Humana in California. Unfortunately, this leads to delayed treatment and unnecessary denials.

Myth vs. Fact: Common Misconceptions

Myth 1: "If my doctor prescribes Skyrizi, Humana has to cover it"

Fact: Prescription alone doesn't guarantee coverage. Humana requires prior authorization for Skyrizi across all Medicare Advantage and commercial plans. Your doctor must submit clinical documentation proving medical necessity and compliance with step therapy requirements.

Myth 2: "I can skip step therapy if Skyrizi works better for my condition"

Fact: Humana's step therapy protocols typically require documented failure or intolerance to TNF inhibitors (like Humira or Enbrel) before approving Skyrizi. The only exceptions are medical contraindications or documented adverse reactions to preferred alternatives.

Myth 3: "California's consumer protection laws override Humana's formulary restrictions"

Fact: While California has strong patient protections, insurers can still maintain formularies and utilization management. However, California's Independent Medical Review (IMR) process gives patients powerful appeal rights—with success rates around 55% for medical necessity denials.

Myth 4: "Generic alternatives are always required first"

Fact: Skyrizi has no generic equivalent. Step therapy requirements focus on trying other biologics in the same class or TNF inhibitors, not generic medications.

Myth 5: "I need to pay out-of-pocket while appealing"

Fact: For urgent medical situations, you can request an expedited appeal. If approved, Humana must provide coverage during the appeal process. California law also allows continued coverage during appeals in certain circumstances.

Myth 6: "Appeals take months and rarely succeed"

Fact: Humana's internal appeals must be decided within specific timeframes: 72 hours for standard Part D appeals, 24 hours for expedited requests. California's IMR process typically resolves cases within 30-45 days, with favorable outcomes for well-documented specialty drug requests.

Myth 7: "Only doctors can file appeals"

Fact: Both patients and prescribers can initiate appeals. However, clinical documentation from your doctor significantly strengthens your case.

What Actually Influences Humana's Approval

Understanding Humana's real decision-making criteria helps you build a stronger case:

Clinical Documentation Requirements

  • Diagnosis confirmation with appropriate ICD-10 codes
  • Disease severity measurements (PASI scores for psoriasis, CDAI for Crohn's)
  • Prior therapy history with specific drugs, doses, duration, and outcomes
  • TB screening results (QuantiFERON or TST within 12 months)
  • Contraindication documentation if step therapy can't be completed

Step Therapy Protocols

Most Humana plans require documented failure of:

  1. At least one TNF inhibitor (adalimumab, etanercept, infliximab)
  2. Adequate trial duration (typically 3-6 months unless adverse events occur)
  3. Objective measures of treatment failure

Medical Necessity Criteria

Your doctor must demonstrate:

  • Skyrizi is appropriate for your FDA-approved indication
  • Expected benefits outweigh risks
  • Proper dosing and monitoring plan
  • No suitable formulary alternatives
Tip: Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific requirements.

Avoid These 5 Costly Mistakes

1. Incomplete Step Therapy Documentation

The mistake: Submitting vague statements like "patient failed Humira." The fix: Provide specific details: drug name, dose, treatment dates, objective measures of failure (lab values, symptom scores), and reason for discontinuation.

2. Missing TB Screening

The mistake: Assuming recent TB tests from another provider are sufficient. The fix: Ensure current TB screening (QuantiFERON or TST) results are included with your PA submission. Most insurers require testing within 12 months of starting biologics.

3. Filing Appeals Too Late

The mistake: Waiting weeks to appeal a denial. The fix: Humana allows 65 days for Medicare appeals, but starting immediately gives you more options and prevents treatment delays.

4. Inadequate Medical Necessity Justification

The mistake: Generic statements about treatment need. The fix: Include specific clinical guidelines, FDA labeling information, and peer-reviewed evidence supporting Skyrizi use for your condition.

5. Not Escalating to California's IMR Process

The mistake: Accepting Humana's final denial without using state-level appeals. The fix: File for Independent Medical Review through the DMHC if your internal appeals fail. California patients have strong success rates with specialty drug appeals.

Your 3-Step Action Plan

Step 1: Gather Required Documentation (Do Today)

  • Insurance card and policy details
  • Complete medical records showing disease severity
  • Documentation of all prior biologic therapies
  • Recent TB screening results
  • Current lab work and imaging

Step 2: Submit Complete Prior Authorization

Work with your doctor to submit PA through Humana's provider portal including:

  • Medical necessity letter citing clinical guidelines
  • Step therapy failure documentation
  • TB and hepatitis B screening results
  • Treatment monitoring plan

Step 3: Prepare for Potential Appeals

If denied:

  1. Internal appeal within 65 days to Humana
  2. California IMR if internal appeal fails
  3. External review through appropriate state agency
From our advocates: We've seen patients succeed by treating the PA process like building a legal case. One patient with Crohn's disease gathered six months of detailed symptom logs, lab results showing inflammation markers, and documentation of three failed TNF inhibitor trials. Their comprehensive submission led to first-time approval, avoiding months of appeals.

California-Specific Resources

State Insurance Regulators

  • DMHC Help Center: 1-888-466-2219 (for HMO/managed care plans)
  • CDI Consumer Hotline: 1-800-927-4357 (for PPO/indemnity plans)
  • Online IMR Application: healthhelp.ca.gov

Humana Contact Information

Patient Assistance Programs

  • Skyrizi Complete: AbbVie's patient support program
  • California Prescription Drug Discount Program: State-sponsored savings
  • Health Consumer Alliance: Free insurance navigation assistance

Professional Support

For complex cases requiring expert appeal assistance, Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance denials by creating evidence-backed appeals tailored to specific payer requirements.

Frequently Asked Questions

How long does Humana's prior authorization process take? Standard PA decisions typically take 72 hours for Part D requests. Electronic submissions through Humana's provider portal often receive responses within one business day.

Can I get Skyrizi covered if it's not on Humana's formulary? Yes, through the formulary exception process. Your doctor must demonstrate that formulary alternatives are not suitable due to effectiveness or safety concerns.

What happens if I need Skyrizi urgently? Request an expedited prior authorization (24-hour decision) if delays would seriously jeopardize your health. Your doctor must certify the urgent medical need.

Does step therapy apply if I failed TNF inhibitors with a different insurance company? Yes, documented failures from other insurers typically satisfy step therapy requirements. Ensure your new doctor has complete records from your previous treatments.

How successful are appeals for Skyrizi denials in California? California's IMR process has approximately 55% success rates for medical necessity denials, particularly when supported by strong clinical documentation and guideline citations.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies and coverage criteria change frequently. Always verify current requirements with your specific Humana plan and consult healthcare providers for medical decisions. For personalized assistance with insurance appeals, contact the California DMHC Help Center at 1-888-466-2219.

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