Medicare Part B covers Skyrizi, but only under specific conditions

Skyrizi (risankizumab) is a biologic medication used to treat moderate to severe plaque psoriasis, Crohn's disease, and ulcerative colitis. Medicare Part B does cover Skyrizi when your doctor prescribes it for one of these conditions and you meet certain requirements. However, coverage is not automatic — your doctor must document medical necessity, and you may face out-of-pocket costs even after Medicare approves it.

Part B covers Skyrizi as an injectable medication administered in a doctor's office or hospital outpatient setting. If Skyrizi is given to you at home by a nurse or if you self-inject, coverage rules change — that scenario falls under Part D (prescription drug coverage) instead, which has different cost-sharing rules. The route of administration matters more than you might expect.

Key Takeaways

  • Medicare Part B covers Skyrizi injections given in a medical office or hospital outpatient department, but your doctor must show the medication is medically necessary for your condition.
  • You will pay a 20% coinsurance amount after your Part B deductible is met, with no annual cap on what you owe out of pocket.
  • If Skyrizi is self-injected at home, it shifts to Part D coverage, which has different cost-sharing and may require prior authorization from your drug plan.
  • Your doctor's office should verify coverage with Medicare before your first injection to confirm there are no coverage barriers.
  • Biosimilars or alternative biologics may be suggested first by Medicare or your plan, depending on what your doctor documents as medically necessary.

How Medicare Part B pays for office-administered Skyrizi

When Skyrizi is injected in a doctor's office or hospital outpatient clinic, Medicare Part B treats it as a physician-administered drug. This means Medicare pays 80% of the approved amount after you have met your Part B deductible (which is $240 in 2024, though this amount changes yearly). You pay the remaining 20% as coinsurance.

The actual cost you see depends on what Medicare's approved amount is for Skyrizi in your area — not what the provider charges. If your doctor's office bills $5,000 for a dose and Medicare's approved amount is $4,000, you pay 20% of $4,000 ($800), not 20% of $5,000. The provider must write off the difference. This is why it matters to use an in-network provider whenever possible.

Unlike Part D drug plans, Part B has no annual out-of-pocket maximum. Once you reach your deductible, you pay coinsurance for every dose for the rest of the year with no upper limit. If you need Skyrizi every four weeks, those 20% coinsurance payments add up quickly.

Medical necessity and prior authorization requirements

Medicare will not pay for Skyrizi unless your doctor documents that you have one of the approved conditions (plaque psoriasis, Crohn's disease, or ulcerative colitis) and that the medication is medically necessary for your case. This usually means you have already tried other treatments that did not work or that you cannot tolerate them.

Your doctor's office typically handles prior authorization by submitting medical records and a letter explaining why Skyrizi is the right choice for you. This process can take several business days. Medicare does not always require prior authorization for Skyrizi, but your specific situation may trigger it — your doctor's office will know based on your diagnosis and treatment history.

If Medicare denies coverage, your doctor can appeal. The appeal process involves submitting additional clinical information. Your doctor's office should tell you whether they plan to appeal or whether they recommend trying a different medication first.

What changes if you self-inject Skyrizi at home

If your doctor prescribes Skyrizi as a self-injection that you administer at home, coverage shifts from Part B to Part D (your prescription drug plan). This is an important distinction because Part D has different rules: you may face a copay or coinsurance depending on your plan's formulary tier, and you may need prior authorization from your drug plan rather than from Medicare directly.

Most Part D plans place Skyrizi on a higher tier because it is a specialty biologic drug. You might pay 25% to 33% coinsurance, or a flat copay of $250 or more per injection, depending on your plan. Some plans require step therapy, meaning you must try and fail a cheaper medication first.

If you are considering home self-injection, ask your doctor's office to contact your Part D plan before you start. The out-of-pocket cost under Part D can be very different from the 20% coinsurance under Part B, and you want to know what to expect.

Costs you will owe out of pocket

Your actual out-of-pocket cost depends on three things: whether you have met your Part B deductible, what Medicare's approved amount is in your region, and whether you have supplemental coverage (Medigap or Medicare Advantage).

If you have not met your $240 Part B deductible, you pay the full approved amount for Skyrizi until the deductible is satisfied. After that, you pay 20% coinsurance per dose. Skyrizi is typically dosed every four weeks, so you would owe coinsurance four times per year at minimum.

If you have a Medigap plan (supplemental insurance), it may cover some or all of your Part B coinsurance, which would lower your out-of-pocket cost significantly. If you have Medicare Advantage instead, your costs depend on your plan's formulary and whether your doctor is in-network. Always check your plan documents or call your plan before starting Skyrizi.

How to verify coverage before your first dose

Do not assume coverage is approved just because your doctor prescribed Skyrizi. Call your doctor's office and ask them to verify coverage with Medicare before your first appointment. They should be able to tell you within one or two business days whether Medicare will pay and what your coinsurance amount will be.

If you have a Medigap or Medicare Advantage plan, your doctor's office may also need to verify coverage with that plan, especially if there are any plan-specific restrictions. Write down the approval code or reference number they give you — you may need it if a billing question comes up later.

If your doctor's office says they cannot verify coverage, you can call Medicare directly at 1-800-MEDICARE (1-800-633-4227) and ask whether Skyrizi is covered for your condition. Have your Medicare number and your diagnosis ready. Medicare's phone lines are busiest early in the morning and on Mondays, so calling mid-week in the afternoon may get you through faster.

What to do if Medicare denies coverage

If Medicare denies Skyrizi, your doctor can request a reconsideration. This involves submitting additional medical evidence — usually notes from your medical record showing why other treatments failed or why you cannot take them. The reconsideration process takes about two weeks.

If reconsideration is denied, you have the right to appeal further, but this process is lengthy and requires more detailed documentation. Your doctor's office should advise you on whether appealing is likely to succeed based on your medical history. Sometimes the faster path is to try a different medication that Medicare covers more readily, then appeal later if that medication does not work.

You can also ask your doctor whether a biosimilar version of a similar biologic might be covered more easily. Medicare sometimes covers biosimilars with fewer restrictions than brand-name biologics, even though they work similarly.

Frequently Asked Questions

Will Medicare pay for Skyrizi if I get it at an urgent care or retail clinic instead of my dermatologist's office?

Medicare Part B covers Skyrizi in any Medicare-approved facility, including urgent care and retail clinics, as long as a doctor orders it and it is administered there. However, you should confirm the facility is Medicare-approved before your appointment. Call the facility directly or ask your doctor's office to verify. Some retail clinics do not bill Medicare, so you could end up paying out of pocket even though you have coverage.

Does my Medigap plan cover the 20% coinsurance for Skyrizi?

Most Medigap plans cover Part B coinsurance, but the amount varies by plan type. Plans C, D, F, G, M, and N all cover some or all of your Part B coinsurance. Check your Medigap policy documents or call your Medigap insurer to confirm. If you have a different plan type, coinsurance coverage may be limited or zero.

What if my doctor wants to prescribe Skyrizi but Medicare says I need to try a different drug first?

This is called step therapy or prior authorization with restrictions. Your doctor can appeal by explaining why the other drug is not appropriate for you — for example, if you had a bad reaction to it or if it did not work. The appeal usually takes one to two weeks. If the appeal is denied, your doctor can try prescribing the other medication anyway and then appeal again after you have tried it.

If I switch from office injections to self-injecting at home, will my costs change?

Yes, costs usually change significantly. Office injections are covered under Part B with 20% coinsurance after your deductible. Self-injections at home are covered under Part D, which may have a higher copay or coinsurance depending on your drug plan's tier. Contact your Part D plan before switching to find out your exact out-of-pocket cost.

Can I use a coupon or patient information program to lower my Skyrizi costs?

The manufacturer of Skyrizi offers a copay information program for patients with Medicare. You can ask your doctor's office for information, or visit the manufacturer's website directly. However, if you are using Medicare, you may have restrictions on using manufacturer coupons — ask your doctor's office whether the information program is compatible with your coverage before enrolling.