Skyrizi is a prescription medication used to treat adults with ulcerative colitis, Crohn’s disease, psoriatic arthritis, and plaque psoriasis. If you or a loved one has been diagnosed with any of these serious illnesses, and your doctor has prescribed Skyrizi for your symptoms, it can be frustrating and stressful to receive a Skyrizi health insurance denial. Insurance companies work hard to maintain their financial bottom line, and a Skyrizi health insurance denial may be cloaked behind such words as “investigational,” “experimental,” or “not medically necessary.”
Should you find yourself in such a position, it is imperative that you have a strong legal advocate by your side who is ready and able to fight for you, your rights, and your future. Attorney Scott Glovsky is experienced and trustworthy and will work tirelessly to ensure you get the medication your doctor prescribed without an insurance company putting their judgment ahead of that of a medical doctor.
What is Skyrizi and What Does It Treat?
Plaque psoriasis on the skin begins in the body. While the cause of plaque psoriasis is unclear, it is widely believed that an overactive immune system is the source. Skyrizi works with the body’s immune system, attaching to a specific protein that causes excess inflammation. When inflammation in the body is reduced, plaques on the skin are also reduced.
Skyrizi is a biologic, similar in nature to a protein called IL-23 found in our own immune systems. Inflammation is the body’s way of telling you something is wrong and protecting you from harm. Too much inflammation means your immune system is working overtime. The theory is that in those with plaque psoriasis, the body produces too much IL-23, leading to painful, itchy, red, burning plaques on the skin.
Plaque psoriasis, a chronic autoimmune disease, affects about 6.7 million adults in the United States. The disease causes cells to reproduce too quickly, resulting in thickened, scaly patches on the skin. These patches are usually found on the elbows, back, knees, and scalp but can also be found on the face, feet, hands, legs, and genitals. Those who smoke, are obese, drink alcohol, have a relative with psoriasis, are Caucasian, or experience depression are more likely to be diagnosed with plaque psoriasis.
Ulcerative colitis and Crohn’s disease are both forms of inflammatory bowel disease. These are lifelong conditions that cause ulcers and inflammation inside the colon. Ulcerative colitis and Crohn’s disease can cause abdominal pain, diarrhea, weight loss, fatigue, and anemia, as well as bloating, fever, depression, and loss of appetite. Skyrizi works in the same way for these illnesses as it does for plaque psoriasis by diminishing inflammation.
Why Would an Insurance Company Issue a Skyrizi Health Insurance Denial?
While there can be legitimate reasons an insurance company can deny an insurance claim—the claim may lack necessary information, the drug or treatment may be specifically denied, or the premiums may not have been paid—it can be just as common for the insurer to deny a claim because it will cost the company money. When an insurer does not want to pay for a drug or a treatment because of the cost, it will sometimes say the drug is not medically necessary, or it is experimental or investigational. As of January 2024, Skyrizi costs $21,017 for one dose, and most people require both starting doses and maintenance doses. This means that even if your doctor believes this drug could significantly help your symptoms, the insurer may balk at paying for the drug.
What Should You Do if Your Skyrizi Prescription Is Denied?
If your Skyrizi prescription is denied by your insurance company, there are things you can do. You should have received a letter detailing why the prescription was denied. If the company needs more information or there were errors in the original submission for payment, the errors can be corrected, and the information can be provided. If this does not result in approval for the drug, you have the right to file an internal appeal.
An internal appeal asks the insurance company to take another look and approve the drug. An internal appeal can virtually always benefit from having a knowledgeable health insurance denial attorney helping you through the process. If the internal appeal is denied, your attorney can guide you to file an external appeal. The external appeal is heard by a neutral third party. If this third party says the insurance company must pay for Skyrizi, then it must do so.
What Insurance Companies Are Likely to Deny Treatments Like Skyrizi?
Any health insurance company can deny a treatment like Skyrizi. Molina has issued Skyrizi health insurance denials in the past. Other health insurance companies who may deny Skyrizi include:
- Anthem Blue Cross
- Blue Shield
- Health Net
- Kaiser
- United Healthcare
- Aetna
- Medi-Cal Managed Care Plans (Anthem Blue Cross, Promise Health Plan, Health Net, Molina)
How the Law Offices of Scott Glovsky Can Help You Get the Medications and Treatments You Need
It can be depressing to have your doctor prescribe a drug that he or she believes will help you with your medical issue only to receive a Skyrizi health insurance denial. Attorney Scott Glovsky can help you get the treatment you need, particularly when an insurance company may be denying the treatment primarily due to cost. Scott and his legal team are extremely experienced in fighting big health insurance corporations and forcing them to pay insurance claims they previously denied.
At the Law Offices of Scott Glovsky, we are on a mission to achieve justice for our clients. We care passionately about you and your cause. We will listen to you, treat you with dignity and respect, and fight for you every step of the way. We only take cases we believe in and will do everything in our power to get you the medical treatments you need. Contact the Law Offices of Scott Glovsky today.