By Counterforce Health Team in Skyrizi (risankizumab) —

Renewing Skyrizi (Risankizumab) Approval with Aetna CVS Health in Texas: Complete Timeline and Documentation Guide

Answer Box: To renew Skyrizi (risankizumab) with Aetna CVS Health in Texas, submit your renewal PA 30-45 days before expiration using Aetna's precertification form. Include updated disease scores, adherence documentation, and liver function tests (for IBD). If your PA lapses, request an emergency override while the renewal processes. Call CVS Specialty and check your PA status at least 6 weeks before your next dose.

Table of Contents

  1. Renewal Triggers: When to Start the Process
  2. Evidence Update Requirements
  3. Essential Renewal Documentation
  4. Timeline and Submission Process
  5. If Your Authorization Lapses
  6. Annual Plan Changes to Monitor
  7. Personal Tracking System
  8. FAQ

Renewal Triggers: When to Start the Process

Your Skyrizi authorization with Aetna CVS Health typically lasts 12 months, but renewal requirements kick in well before expiration. Here's when to act:

Critical Timing Windows

6-8 weeks before expiration:

  • Check your CVS Caremark member portal for PA status and end date
  • Schedule follow-up appointment with your prescribing specialist
  • Request updated lab work if needed (especially liver function tests for Crohn's/UC patients)

4-6 weeks before expiration:

2 weeks before expiration:

  • Follow up on PA status if no decision received
  • Request expedited review if approaching dose date
Tip: Aetna standard PA decisions take up to 14 days, but complex cases or incomplete submissions can extend to 30-45 days.

Early Warning Signs

Start your renewal process immediately if you notice:

  • CVS Specialty unable to ship your next dose
  • Member portal showing "authorization needed"
  • Denial or "pending" status on recent refill attempts

Evidence Update Requirements

Aetna requires specific clinical evidence to demonstrate continued medical necessity for Skyrizi renewal.

Response to Therapy Documentation

For Plaque Psoriasis:

  • Current body surface area (BSA) percentage
  • Static Physician Global Assessment (sPGA) score
  • PASI score improvement from baseline
  • Patient-reported quality of life measures

For Psoriatic Arthritis:

  • Joint count assessments (tender/swollen)
  • Functional status improvements
  • Pain scale ratings
  • Physical examination findings

For Crohn's Disease:

  • Crohn's Disease Activity Index (CDAI) or equivalent symptom scores
  • Stool frequency and consistency logs
  • Abdominal pain assessments
  • Inflammatory markers (CRP, fecal calprotectin when available)

Required Laboratory Monitoring

Based on FDA labeling requirements, renewal documentation must include:

All Indications:

  • Infection screening and TB monitoring results
  • Documentation of no active serious infections

IBD Patients (Crohn's/UC) - Mandatory:

  • Baseline liver enzymes (AST/ALT) and bilirubin before starting
  • Follow-up liver function tests during induction (by Week 12)
  • Ongoing LFT monitoring per clinical status

Adherence Documentation

Aetna policies typically require ≥85% adherence documentation through:

  • CVS Specialty refill history
  • Provider attestation of patient compliance
  • Explanation of any treatment interruptions (surgery, infections)

Essential Renewal Documentation

Core Renewal Packet Components

Document Purpose Source
Aetna Skyrizi Precertification Form Official PA renewal request Prescriber completes
Updated Letter of Medical Necessity Clinical justification for continuation Prescribing specialist
Recent clinic notes Current disease status and exam findings Medical records
Laboratory results Safety monitoring (especially LFTs for IBD) Lab reports
Disease assessment scores Objective response measurements Clinical documentation

Letter of Medical Necessity Update Structure

Your specialist's renewal letter should address:

  1. Current diagnosis confirmation with ICD-10 codes
  2. Treatment response summary: "Patient has achieved [specific improvements] since starting Skyrizi"
  3. Continued medical necessity: "Discontinuation would likely result in disease relapse"
  4. Safety profile: "Patient tolerates therapy well with no significant adverse events"
  5. Alternative therapy assessment: "Other available treatments remain inappropriate due to [prior failures/contraindications]"
Clinician Corner: Include specific numeric improvements (e.g., "PASI improved from 18.4 to 2.1" or "CDAI decreased from 285 to 95") rather than general statements about improvement.

Timeline and Submission Process

Standard Renewal Timeline

Week -6 to -4: Preparation phase

  • Patient schedules specialist follow-up
  • Lab work completed if required
  • Clinical assessments documented

Week -4 to -2: Submission phase

  • Provider submits complete renewal PA
  • All supporting documentation included
  • Confirmation of receipt obtained

Week -2 to 0: Decision phase

  • Aetna reviews submission (up to 14 days standard)
  • Follow up if no decision by Week -1
  • Request expedited review if urgent

Submission Methods

Electronic submission (preferred):

  • Aetna provider portal for ePA
  • CVS Caremark prior authorization system

Alternative methods:

  • Fax: Use provider-specific PA fax number (verify current number through Aetna provider portal)
  • Phone: Provider services line for urgent cases

Expected Decision Timeframes

  • Standard renewal: 14 business days maximum
  • Expedited/urgent: 72 hours (24 hours after prescriber support statement)
  • Incomplete submissions: Additional 14 days after missing information provided

If Your Authorization Lapses

Immediate Actions When PA Expires

Step 1: Verify status Call CVS Specialty member services: "Is my Skyrizi PA active? What's the expiration date?"

Step 2: Request emergency coverage Ask both CVS Specialty and Aetna member services: "Can you provide a temporary override or emergency fill while my renewal PA is processed?"

Step 3: Expedite the renewal Have your prescriber:

  • Submit urgent/expedited PA with medical necessity documentation
  • Include statement about risk from treatment interruption
  • Request peer-to-peer review if needed

Bridge Therapy Options

While not guaranteed, several mechanisms may provide temporary coverage:

Plan-level overrides:

  • Emergency fill provisions (varies by specific Aetna product)
  • Transition supply for continuing therapy
  • Temporary PA extensions during administrative delays

State-specific protections:

  • Texas emergency supply regulations for maintenance medications
  • Expedited coverage determination requirements (72 hours for urgent cases)

Medicare/Medicaid considerations:

  • Medicare plans must process expedited requests within 72 hours when delay may jeopardize health
  • Medicaid emergency supply provisions may apply to Aetna Better Health Texas members

When Coverage Is Denied

If your renewal is denied, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and creates point-by-point rebuttals using FDA labeling, peer-reviewed studies, and payer-specific criteria.

Texas appeal rights:

  1. Internal appeal with Aetna (must file within 180 days)
  2. External review through Texas Department of Insurance IRO process
  3. Expedited external review available for urgent cases (decision within 72 hours)

Annual Plan Changes to Monitor

Formulary Updates to Track

Aetna formularies change multiple times per year. Monitor for:

January changes (major annual updates):

  • Tier placement modifications
  • New prior authorization requirements
  • Step therapy additions or modifications

Mid-year updates (quarterly):

  • New biosimilar additions affecting Skyrizi tier status
  • Utilization management criteria changes
  • Quantity limit adjustments

How to Stay Informed

For Aetna Standard Plans:

For Medicare plans:

  • Monitor monthly formulary updates online
  • Watch for mid-year formulary exception notices

For employer/federal plans:

  • Review quarterly Summary of Changes documents
  • Check Advanced Control formulary updates

Red Flags Requiring Action

Contact your provider immediately if you notice:

  • Skyrizi moved to higher tier or non-formulary status
  • New step therapy requirements added
  • Prior authorization criteria becoming more restrictive

Personal Tracking System

Renewal Tracking Template

Item Current Status Next Action Due Date
PA expiration date [Your date] Schedule renewal 6 weeks prior
Last disease assessment [Date/scores] Update evaluation Before renewal
Required labs [Date/results] Repeat if >6 months old Before submission
Specialist appointment [Date scheduled] Complete visit 4-6 weeks before
PA submission [Status] Follow up 2 weeks after

Key Contacts to Maintain

  • CVS Specialty: Member services number from your card
  • Aetna member services: Number from insurance card
  • Prescriber's office: Direct PA contact person
  • Texas Department of Insurance: 1-800-252-3439 (consumer help)

FAQ

How long does Aetna CVS Health PA renewal take in Texas? Standard renewals take up to 14 business days. Expedited requests for urgent cases are decided within 72 hours.

What if Skyrizi becomes non-formulary on my plan? Request a formulary exception with documentation of medical necessity and prior therapy failures. Your provider can submit this with the renewal PA.

Can I request an expedited renewal appeal? Yes, if treatment interruption could seriously jeopardize your health. Your prescriber must certify the urgent medical need.

Do step therapy requirements apply to renewals? Generally no, if you're already stable on Skyrizi. However, new plan year changes might trigger step therapy reviews for some members.

What happens if I miss doses during a PA lapse? Contact your prescriber immediately about restarting protocols. For Crohn's disease, extended interruptions may require reinduction dosing.

Are liver function tests required for all Skyrizi patients? LFT monitoring is mandatory for IBD indications (Crohn's disease, ulcerative colitis) but not specifically required for psoriasis/psoriatic arthritis, though many providers monitor routinely.

How do I check my current PA status? Log into your CVS Caremark member portal or call the member services number on your insurance card. Ask specifically for PA expiration date and any pending requests.

This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider regarding your specific treatment plan. For assistance with Texas insurance appeals, contact the Texas Department of Insurance at 1-800-252-3439 or visit tdi.texas.gov.

Sources & Further Reading

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