Skyrizi (Risankizumab) Denied by Insurance: Appeal

Skyrizi (risankizumab) is a biologic medication developed by AbbVie that selectively inhibits IL-23, a cytokine that plays a central role in inflammatory skin and bowel diseases. It is FDA-approved for moderate-to-severe plaque psoriasis, active psoriatic arthritis, moderately to severely active Crohn's disease, and moderately to severely active ulcerative colitis. Skyrizi has demonstrated impressive clinical response rates in its trial programs — PASI 90 and even PASI 100 responses in psoriasis trials, and high clinical remission rates in Crohn's and UC studies. Despite this clinical profile, insurance denials are common, and appealing successfully requires knowing exactly what documentation insurers are looking for.

Why Insurance Denies Skyrizi

Step therapy is the primary barrier. For psoriasis and psoriatic arthritis, insurers typically require failure of conventional systemic therapies (methotrexate, cyclosporine, acitretin, or apremilast) before approving any biologic, and then may require failure of a TNF inhibitor before approving a newer-generation IL-23 inhibitor like Skyrizi. The step therapy ladder can involve years of suboptimal treatment before a patient is allowed access to a drug that might have worked better from the start.

Prior Authorization Denied: How to Appeal" class="auto-link">Prior authorization is required for all Skyrizi prescriptions across all indications. PA criteria typically require: a confirmed diagnosis of moderate-to-severe disease, documentation of prior therapy and the reason it failed, clinical severity scores, and often a physician attestation that Skyrizi is the most appropriate therapy.

Severity requirements can result in denial if the insurer determines your disease is mild rather than moderate-to-severe. Insurers sometimes interpret borderline severity scores strictly, denying coverage even when the prescribing physician believes systemic therapy is appropriate.

Formulary positioning is a factor because some plans have preferred competing IL-23 inhibitors (such as Tremfya or Ilumya) and will deny Skyrizi without a formulary exception showing that Skyrizi is medically necessary over the preferred alternative.

IBD indication lag can affect Crohn's and UC patients because Skyrizi's approvals for these indications came after its psoriasis approval, and some insurer coverage policies have not fully updated to reflect the Crohn's and UC approvals.

How to Appeal a Skyrizi Denial

Document your PASI/BSA/DLQI scores for psoriasis. PASI (Psoriasis Area and Severity Index) scores of 12 or higher, BSA involvement of 10% or more, or DLQI scores significantly impacting quality of life all support a finding of moderate-to-severe disease. Your dermatologist should record these scores at each visit and provide them with your appeal.

Detail every prior systemic therapy. Your appeal must include a complete medication history: drug names, start and stop dates, doses, and specific reasons for discontinuation. For conventional therapies, document whether inadequate response or intolerable side effects were the reason for stopping. For TNF inhibitors, include any disease activity scores from that treatment period showing persistent or worsening disease.

Support a step therapy override for IBD. For Crohn's disease and UC, provide recent endoscopy reports or cross-sectional imaging confirming active, moderate-to-severe disease. Include CDAI/Harvey-Bradshaw scores for Crohn's and Mayo Clinic Scores for UC. If you have previously tried TNF inhibitors or conventional immunomodulators and they failed, document this with the same level of clinical detail described for psoriasis.

Obtain a medical necessity letter from your specialist. Your dermatologist, rheumatologist, or gastroenterologist should write a letter explaining why Skyrizi is the appropriate choice for your specific case — including your individual clinical profile, treatment history, and the potential risks of continued inadequate therapy.

Reference clinical data and guidelines. The IMMhance, IMMvoke, and IMMerge trials demonstrated high PASI 90 and PASI 100 response rates for Skyrizi in psoriasis. For IBD, the ADVANCE, MOTIVATE, and FORTIFY trials showed strong clinical remission rates. AAD guidelines support IL-23 inhibitors as appropriate treatment for moderate-to-severe psoriasis after conventional therapy failure.

Request peer-to-peer review. This is especially effective when the denial is based on step therapy requirements, as your physician can directly explain to the insurer's medical reviewer why a specific intermediate step is clinically inappropriate for your case.

Patient Assistance Programs

AbbVie offers Skyrizi Complete, a patient support program that includes copay assistance for commercially insured patients (reducing out-of-pocket costs significantly) and a free drug program for qualifying uninsured or underinsured patients. Contact Skyrizi Complete at 1-866-SKYRIZI or visit skyrizi.com/support.

Skyrizi's list price varies by indication and infusion vs. injection formulation but can reach $150,000 or more per year, making assistance programs essential.

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Related Reading:

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• What Is Step Therapy?