By Counterforce Health Team in Skyrizi (risankizumab) —

Renewing Skyrizi (Risankizumab) Coverage with UnitedHealthcare in Ohio: Timeline, Documentation, and Appeal Process

Answer Box: Renewing Skyrizi Coverage in Ohio

Quick Answer: Skyrizi (risankizumab) requires prior authorization renewal with UnitedHealthcare every 12 months. Submit renewal requests 30 days before expiration through the OptumRx portal or fax (1-844-403-1029). Required documentation includes positive clinical response evidence, PASI scores for psoriasis, and baseline liver function tests. If denied, you have 180 days to appeal internally, then request external review through Ohio Department of Insurance at 1-800-686-1526.

Start Today: Check your current authorization expiration date on your UnitedHealthcare member portal or prescription bottle label.

Table of Contents

  1. Renewal Triggers: When to Start Early
  2. Evidence Update: What Documentation You Need
  3. Renewal Packet: Must-Include Documents
  4. Timeline: Submission Windows and Decision Deadlines
  5. If Coverage Lapses: Bridge Options
  6. Annual Changes: What to Re-Verify
  7. Appeals Process in Ohio
  8. Personal Tracker Template

Renewal Triggers: When to Start Early

Standard Renewal Window

UnitedHealthcare OptumRx requires Skyrizi prior authorization renewal every 12 months. Your authorization doesn't automatically renew—you must submit a new request before expiration to avoid treatment interruption.

Start 60 Days Early If: You're switching plans, moving to Ohio from another state, or have had previous denials with UnitedHealthcare.

Signs You Should Accelerate the Process

  • Lab Results Pending: If recent liver function tests or TB screening aren't complete
  • Formulary Changes: UnitedHealthcare announces plan design updates for the new year
  • Provider Changes: Your prescribing specialist has changed since initial approval
  • Diagnosis Updates: New ICD-10 codes or additional indications (e.g., adding psoriatic arthritis to existing psoriasis coverage)

Evidence Update: What Documentation You Need

Clinical Response Documentation

UnitedHealthcare requires proof of positive clinical response for renewal. According to their prior authorization policy, this includes:

For Psoriasis:

  • PASI score improvement from baseline (target: PASI 75 or better)
  • Static Physician Global Assessment (sPGA) of 0 or 1
  • Photographic documentation (if available)

For Psoriatic Arthritis:

  • Joint count assessments
  • Patient-reported outcome measures
  • Functional improvement documentation

For IBD (Crohn's/Ulcerative Colitis):

  • Clinical remission indicators
  • Biomarker improvements (CRP, fecal calprotectin)
  • Endoscopic findings (if recent procedures performed)

Required Laboratory Monitoring

Baseline liver enzymes and bilirubin levels must be documented for renewal. For IBD patients, ongoing monitoring during the first 12 weeks is required.

Adherence Verification

Your prescriber must document adherence to therapy of at least 85% of the time as verified through pharmacy records or patient reporting.

Renewal Packet: Must-Include Documents

Core Requirements Checklist

  • OptumRx Skyrizi Prior Authorization Request Form (current version)
  • Medical records showing treatment response
  • Accurate ICD-10 codes: L40.0 (psoriasis), M07.3 (psoriatic arthritis), K50.9 (Crohn's), K51.9 (ulcerative colitis)
  • Prescriber credentials confirmation (dermatology, rheumatology, or gastroenterology specialty)
  • Laboratory results: liver function tests, TB screening status
  • Prior authorization history from previous approvals

Letter of Medical Necessity Update Structure

When updating your clinical justification letter, include:

  1. Current disease status with objective measures
  2. Treatment response timeline since last approval
  3. Adherence documentation and any missed doses with explanations
  4. Absence of serious adverse events or management of any that occurred
  5. Continued medical necessity despite response (maintenance therapy rationale)

Timeline: Submission Windows and Decision Deadlines

Action Timeline Notes
Submit Renewal Request 30 days before expiration Prevents treatment gaps
Standard Processing 24-72 hours Most renewals approved quickly if complete
Automated Approval Under 30 seconds When all criteria clearly met
Authorization Duration 12 months Standard renewal period
Appeal Deadline 180 days from denial Ohio state requirement

Submission Methods

Preferred: UnitedHealthcare Provider Portal for fastest processing

Alternative: OptumRx fax line at 1-844-403-1029

Member Services: 1-800-358-0114 for status checks

If Coverage Lapses: Bridge Options

Immediate Steps if Authorization Expires

  1. Contact your specialty pharmacy immediately to discuss temporary supply options
  2. File expedited appeal if renewal was denied (72-hour processing for urgent cases)
  3. Explore manufacturer assistance through AbbVie's patient support programs

AbbVie Patient Assistance Programs

Skyrizi Complete Savings Program: Potential $5 copays for eligible commercial insurance patients. Verify eligibility and current terms.

Free Drug Program: For patients 63 or younger with commercial insurance denials, AbbVie provides Skyrizi at no charge for up to two years. Requires:

  • Valid prescription
  • Insurance denial on file
  • Submitted coverage appeal
  • Resubmission of appeal every 180 days
From Our Advocates: "We've seen patients successfully bridge 2-3 month coverage gaps using manufacturer assistance while pursuing external review in Ohio. The key is filing the external review request immediately after internal appeals are exhausted—don't wait for the manufacturer program approval first."

Coordination with Specialty Pharmacy

Specialty pharmacies can often provide:

  • Emergency fills (limited supply while authorization pending)
  • Prior authorization coordination with your provider's office
  • Insurance navigation support including appeal assistance

Annual Changes: What to Re-Verify

Plan Design Verification

Each January, confirm:

  • Formulary tier placement for Skyrizi (specialty tier typical)
  • Prior authorization requirements (may change year-to-year)
  • Step therapy protocols and preferred alternatives
  • Quantity limits and dosing restrictions
  • Site of care requirements (home vs. clinic administration)

Ohio-Specific Considerations

External Review Rights: Ohio maintains robust external review protections. The Ohio Department of Insurance oversees Independent Review Organizations (IROs) that can overturn UnitedHealthcare denials.

Self-Funded Plan Alert: Many Ohio employers offer self-funded plans governed by federal ERISA law rather than Ohio state regulations. Confirm your plan type to understand which appeals process applies.

Appeals Process in Ohio

Internal Appeals with UnitedHealthcare

First Level:

  • Deadline: 180 days from denial notice
  • Processing time: 30 days standard, 72 hours expedited
  • Submission: UnitedHealthcare member portal, fax, or mail

Required for Appeal:

  • Original denial letter
  • Updated clinical documentation
  • Prescriber statement supporting medical necessity

Ohio External Review Process

After exhausting internal appeals, Ohio residents can request independent external review through the Ohio Department of Insurance.

Key Details:

  • Cost: Free to patients
  • Deadline: 180 days from final internal denial
  • Contact: 1-800-686-1526
  • Processing: 30 days standard, 72 hours expedited
  • Decision: Binding on UnitedHealthcare if coverage approved

When to Contact Ohio Regulators

The Ohio Department of Insurance Consumer Services Division can assist with:

  • Appeals process questions
  • External review eligibility determinations
  • Insurer compliance issues
  • Navigation of complex denials

Personal Tracker Template

Renewal Checklist

Current Authorization Details:

  • Approval date: ___________
  • Expiration date: ___________
  • Authorization number: ___________
  • Approved indication: ___________

Documentation Status:

  • Recent PASI score: _______ (date: _______)
  • Liver function tests: Normal/Abnormal (date: _______)
  • TB screening: Current through: _______
  • Adherence log: ____% over past 6 months
  • Provider appointment scheduled: _______

Submission Tracking:

  • Renewal submitted: _______
  • Confirmation received: _______
  • Decision date: _______
  • New authorization number: _______

Frequently Asked Questions

How long does UnitedHealthcare prior authorization take in Ohio? Standard renewals process within 24-72 hours if documentation is complete. New authorizations may take up to 15 business days.

What if Skyrizi isn't on my formulary? Request a formulary exception with clinical justification. UnitedHealthcare must provide written response within 72 hours for expedited requests.

Can I request expedited renewal? Yes, if delays would seriously jeopardize your health. Contact your provider to submit an expedited request with supporting clinical documentation.

Does step therapy apply to renewals? Generally no, if you're already stable on Skyrizi. However, plan changes may trigger new step therapy requirements—verify annually.

What happens if I miss my renewal deadline? File immediately even if past expiration. UnitedHealthcare may approve retroactively, especially with clinical justification for the delay.

Counterforce Health helps patients and clinicians navigate complex prior authorization requirements and turn denials into successful appeals. Our platform analyzes denial letters, identifies specific policy criteria, and generates targeted rebuttals with the right clinical evidence and procedural requirements. If you're facing challenges with Skyrizi coverage through UnitedHealthcare, Counterforce Health can help streamline your appeals process with payer-specific workflows and evidence-backed documentation.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual plan terms and clinical circumstances. Always consult with your healthcare provider and insurance plan for specific coverage questions. For assistance with Ohio insurance appeals, contact the Ohio Department of Insurance at 1-800-686-1526.

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