By Counterforce Health Team in Skyrizi (risankizumab) —

Skyrizi (Risankizumab) Approval with Blue Cross Blue Shield in New Jersey: Complete Guide to Prior Authorization, Appeals, and Coverage

Quick Answer: Getting Skyrizi Covered by Blue Cross Blue Shield in New Jersey

Horizon Blue Cross Blue Shield of New Jersey requires prior authorization for Skyrizi (risankizumab), a specialty medication. Start by having your prescriber submit a PA request through the Horizon provider portal within 72 hours for standard approval. If denied, you have two internal appeal levels, then can file an external review with New Jersey's IHCAP program through Maximus Federal Services within 4 months. The fastest path: ensure your doctor includes tuberculosis screening results, documentation of prior treatment failures, and meets the plan's step therapy requirements in the initial submission.

Table of Contents

  1. Coverage Basics: Is Skyrizi Covered?
  2. Prior Authorization Process
  3. Timeline and Approval Speed
  4. Medical Necessity Criteria
  5. Cost and Specialty Pharmacy Requirements
  6. Common Denial Reasons and Solutions
  7. Appeals Process in New Jersey
  8. Renewal and Reauthorization
  9. When to Escalate
  10. Frequently Asked Questions

Coverage Basics: Is Skyrizi Covered?

Skyrizi (risankizumab) is covered by Horizon Blue Cross Blue Shield of New Jersey, but it's classified as a specialty medication requiring prior authorization. The drug is listed on their prior authorization/medical necessity determination medicine list and must be filled through designated specialty pharmacies.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Doctor must get approval before prescribing Horizon PA Forms
Specialty Pharmacy Must fill at approved specialty pharmacy Network List
Step Therapy May need to try other treatments first Plan formulary document
Quantity Limits Restricted to specific dosing schedule Member ID card details
TB Screening Required for Crohn's/UC indications FDA prescribing information

Coverage varies by specific plan type (Commercial Classic, Health Insurance Marketplace, Medicare plans), so verify your exact formulary through the Prime Therapeutics tool or call Pharmacy Member Services at 1-800-370-5088.

Prior Authorization Process

Step-by-Step: Fastest Path to Approval

  1. Verify Coverage (Patient or clinic staff)
    • Check your member ID card for formulary information
    • Use the Prime Therapeutics drug lookup tool
    • Expected time: 5 minutes
  2. Gather Required Documentation (Prescriber)
    • Medical records showing diagnosis (ICD-10 codes)
    • Prior treatment history and failures
    • TB screening results (for IBD indications)
    • Expected time: 30 minutes
  3. Submit PA Request (Prescriber)
    • Complete the Prior Authorization form
    • Submit via Horizon provider portal (preferred) or fax
    • Expected time: 72 hours for decision
  4. Track Status (Clinic staff)
    • Monitor through provider portal
    • Follow up if no response within 3 business days
    • Expected time: Real-time updates
  5. Fill Prescription (Patient)
    • Use only designated specialty pharmacies
    • Provide insurance and prescription information
    • Expected time: 3-5 business days for delivery
Tip: For urgent cases requiring expedited review, call customer service immediately and mark your request as urgent with clinical justification. Decisions come within 24-48 hours.

Timeline and Approval Speed

Horizon BCBS New Jersey follows these standard timelines:

  • Routine PA Decision: 72 hours (3 business days)
  • Expedited/Urgent: 24 hours with clinical justification
  • Specialty Pharmacy Fill: 3-5 business days after approval

For medical injectables like Skyrizi, Horizon offers a streamlined submission process to reduce processing time. Submit through their provider portal for the fastest turnaround.

Medical Necessity Criteria

Based on comparable BCBS policies, Skyrizi approval typically requires:

For Plaque Psoriasis

  • Patient ≥18 years (or ≥6 years for pediatric approval)
  • Moderate-to-severe disease: ≥10% body surface area affected
  • Inadequate response to conventional therapies (methotrexate, phototherapy)
  • May require prior biologic trial and failure
  • Prescribed by or in consultation with dermatologist

For Crohn's Disease and Ulcerative Colitis

  • Tuberculosis screening required (major denial reason if missing)
  • Documentation of prior biologic failure or intolerance
  • Initial approval: up to 3 IV infusion doses for induction
  • Continued therapy: up to 1 year with documented response

Clinician Corner: Medical Necessity Letter Checklist

When submitting your PA request, include:

  • Problem statement: Specific diagnosis with ICD-10 codes
  • Prior treatments: Dates, medications tried, reasons for discontinuation
  • Clinical rationale: Why Skyrizi is medically necessary for this patient
  • Dosing plan: FDA-approved dosing per package insert
  • Monitoring plan: How you'll track response and safety

Reference the FDA prescribing information and relevant clinical guidelines to support your request.

Cost and Specialty Pharmacy Requirements

Skyrizi must be filled through Horizon's specialty pharmacy network, which includes:

  • Accredo Specialty Pharmacy
  • AllianceRx Walgreens Prime
  • CVS Specialty Pharmacy
  • Optum Specialty Pharmacy

Find the complete network at horizonblue.com/specialtypharmacynetwork.

Important: Skyrizi for self-administration is covered under your pharmacy benefit, while physician-administered doses fall under your medical benefit. Verify which applies to your treatment plan.

Savings Options

  • Skyrizi Complete Savings Card: May reduce copay to $0 per dose for eligible commercial patients (not available for government-funded plans)
  • Patient assistance programs: Check skyrizi.com for current offerings

Counterforce Health helps patients navigate complex prior authorization requirements by turning insurance denials into targeted, evidence-backed appeals. Their platform analyzes denial letters and drafts point-by-point rebuttals aligned to each plan's specific criteria.

Common Denial Reasons and Solutions

Denial Reason How to Fix It Required Documentation
Missing TB screening Submit negative TB test results QuantiFERON-Gold or PPD test
Quantity limit exceeded Verify dosing matches FDA label Package insert dosing schedule
Step therapy not met Document prior treatment failures Pharmacy records, clinical notes
Non-FDA indication Confirm on-label use only FDA prescribing information
Missing clinical documentation Provide complete medical records Progress notes, lab results

The most common denial reason across BCBS plans is failure to document tuberculosis screening for inflammatory bowel disease indications. Ensure this is completed before submitting your PA request.

Appeals Process in New Jersey

If Horizon BCBS denies your Skyrizi request, New Jersey offers a comprehensive appeals process:

Internal Appeals (Required First)

  1. Stage 1 - Informal Reconsideration
    • Submit within 180 days of denial
    • Decision within 10 calendar days (72 hours if urgent)
  2. Stage 2 - Formal Internal Appeal
    • Submit if Stage 1 is denied
    • Decision within 20 business days (72 hours if urgent)

External Review - New Jersey IHCAP

After exhausting internal appeals, you can file with New Jersey's Independent Health Care Appeals Program (IHCAP):

  • Who handles it: Maximus Federal Services
  • Deadline: 4 months after Stage 2 denial
  • Cost: Free to patients
  • Timeline: 5 business days for preliminary review, 45 days for final decision (48 hours if expedited)

File online: njihcap.maximus.com Phone help: 1-888-393-1062

Note: New Jersey's external review has a strong track record. About half of external appeals nationwide favor consumers, and the decision is binding on insurers.

Renewal and Reauthorization

Skyrizi prior authorizations typically require renewal every 6-12 months. Horizon may request:

  • Updated clinical notes showing treatment response
  • Current lab values
  • Confirmation that the medication remains medically necessary

Start your renewal process 30 days before expiration to avoid treatment gaps. Your specialty pharmacy will often help coordinate this process.

When to Escalate

Contact these resources if you need additional help:

  • New Jersey Department of Banking and Insurance Consumer Hotline: 1-800-446-7467
  • IHCAP-specific questions: 1-888-393-1062
  • Horizon BCBS Member Services: Number on your member ID card

For complex cases involving multiple denials, Counterforce Health specializes in creating comprehensive appeal packages that address each plan's specific requirements and cite relevant medical literature.

Frequently Asked Questions

How long does Horizon BCBS prior authorization take in New Jersey? Standard PA decisions come within 72 hours. Expedited requests for urgent medical situations are decided within 24 hours.

What if Skyrizi is non-formulary on my plan? You can request a formulary exception through your prescriber. Include medical necessity documentation and evidence that preferred alternatives aren't appropriate.

Can I request an expedited appeal if denied? Yes, if a delay would cause serious harm to your health. Mark your appeal as expedited and provide clinical justification for urgency.

Does step therapy apply if I tried other biologics outside New Jersey? Yes, prior treatment history from other states counts toward step therapy requirements. Provide complete pharmacy and medical records.

What happens if I miss an appeal deadline? You may lose your right to external review. However, you can always resubmit a new PA request with additional documentation.

Can my doctor request a peer-to-peer review? Yes, after an initial denial, your prescriber can request to speak directly with Horizon's medical director to discuss your case.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently. Always verify current requirements with your specific plan and consult with your healthcare provider about treatment decisions.

Sources & Further Reading

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