Medicare Part D covers Skyrizi, but your out-of-pocket cost depends on which plan you have and which pharmacy you use

Skyrizi (risankizumab) is a biologic medication used to treat moderate to severe plaque psoriasis, Crohn's disease, and ulcerative colitis. Medicare Part D — the prescription drug coverage that comes with Original Medicare — does cover Skyrizi, but it is not automatically covered at the same price at every pharmacy or under every plan. Your actual cost will depend on your specific Part D plan's formulary (the list of drugs it covers), which tier the drug is placed on, and whether you use a pharmacy in your plan's network.

Because Skyrizi is a biologic medication, it is typically placed on a higher tier of your Part D plan, which means you will likely pay a larger share of the cost than you would for a generic drug. The drug is also usually subject to prior authorization, meaning your doctor must get approval from your insurance plan before the pharmacy will fill your prescription.

Key Takeaways

  • Medicare Part D covers Skyrizi, but it is usually placed on a higher cost tier, so your out-of-pocket expense will be substantial.
  • Your Part D plan's formulary determines whether Skyrizi is covered and at what tier; you can check your plan's formulary on your insurer's website or by calling the plan directly.
  • Your doctor will likely need to request prior authorization from your Part D plan before the pharmacy will dispense Skyrizi.
  • If your current Part D plan does not cover Skyrizi or places it on a very high tier, you may be able to switch to a different plan during the annual open enrollment period in October and November.

How to find out what your plan will charge

The fastest way to learn your actual out-of-pocket cost is to contact your Part D plan directly. You can find the phone number on your insurance card or on Medicare.gov. Have your prescription ready — your doctor will need to provide the dose and frequency — and ask the plan representative for the cost at your preferred pharmacy.

You can also check your plan's formulary online. Most insurers post their formularies on their websites, and you can search for Skyrizi by name. The formulary will tell you which tier the drug is on and whether prior authorization is required. If you are not sure how to find your plan's website, call 1-800-MEDICARE and ask for the phone number of your Part D plan.

Prices vary significantly between pharmacies, even within the same plan. If the cost at your usual pharmacy is high, ask your doctor or pharmacist whether a different pharmacy in your plan's network might charge less. Some specialty pharmacies that handle biologic medications may have lower copays than retail chains.

Prior authorization and what it means for your timeline

Prior authorization is a requirement that your doctor submit paperwork to your Part D plan showing that Skyrizi is medically necessary for your condition. The plan reviews this information and decides whether to approve the prescription. This process usually takes three to five business days, but it can take longer if the plan requests additional information from your doctor.

Your doctor's office typically handles the prior authorization request, but it is worth calling them to confirm they have submitted it and to ask how long they expect approval to take. If you need the medication urgently, let your office know — they may be able to expedite the request or provide a temporary supply while waiting for approval.

Some Part D plans also require step therapy, which means you may need to try a different, usually less expensive medication first before the plan will cover Skyrizi. If your plan has this requirement and you believe Skyrizi is the right medication for you, your doctor can request an exception.

What to do if your plan does not cover Skyrizi or the cost is too high

If your current Part D plan does not cover Skyrizi or places it on a tier that makes it unaffordable, you have options. During the annual open enrollment period — October 15 through December 7 each year — you can switch to a different Part D plan. Before you switch, use the Medicare Plan Finder tool on Medicare.gov to compare plans and see which ones cover Skyrizi at a lower cost tier.

You can also ask your doctor whether there is a generic or lower-cost alternative medication that might work for your condition. Your doctor knows your medical history and can advise whether another drug is appropriate.

Additionally, the manufacturer of Skyrizi offers a patient information program that may reduce your out-of-pocket cost if you meet income requirements. Ask your doctor's office or pharmacist for information about this program, or contact the manufacturer directly.

Understanding Part D cost tiers and how they affect your bill

Part D plans organize drugs into tiers, usually ranging from tier 1 (lowest cost) to tier 5 (highest cost). Generic drugs are typically on tier 1 or 2, while brand-name drugs and biologics are on tier 3, 4, or 5. Skyrizi, being a brand-name biologic, is usually on tier 4 or 5.

Your cost at each tier depends on your plan. Some plans charge a flat copay per prescription — for example, $50 for a tier 4 drug. Others use coinsurance, meaning you pay a percentage of the drug's cost, such as 25 or 30 percent. Because Skyrizi is expensive, coinsurance can result in a very high bill. Ask your plan whether it uses copays or coinsurance for tier 4 and 5 drugs.

Once you reach your plan's out-of-pocket spending limit (which varies by plan but is set by Medicare each year), your plan pays the full cost of your medications for the rest of the year. Understanding how much you need to spend to reach this limit can help you plan your budget.

Manufacturer discounts and patient information programs

The company that makes Skyrizi offers a copay information program for people with Medicare Part D coverage. This program can reduce your copay or coinsurance to as little as $0 per month, depending on your income and plan. To find out whether you are may be able to access, ask your doctor's office, call the manufacturer's patient support line, or visit the manufacturer's website.

You will need to provide proof of income and enrollment in Medicare Part D. The process usually takes a few days to a week. Once you are enrolled in the information program, the discount is applied at the pharmacy when you fill your prescription.

Some nonprofit organizations also offer medication information for people who cannot afford their prescriptions. The Patient Advocate Foundation and NeedyMeds are two resources that maintain databases of information programs. Your doctor's office or social worker may also know of local programs in your area.

What happens if you switch Medicare plans mid-year

You can only change your Part D plan during the annual open enrollment period in the fall, with one exception: if you have a may have access to life event — such as losing other prescription drug coverage, moving to a new state, or experiencing a significant change in income — you may be able to switch plans outside the enrollment period. Contact Medicare at 1-800-MEDICARE to ask whether your situation qualifies.

If you are currently on a Part D plan that does not cover Skyrizi well and you cannot wait until October, talk to your doctor about whether a different medication might work for you in the meantime. Your doctor can also help you document your medical need for Skyrizi, which may support an exception request to your current plan.

Frequently Asked Questions

Will Medicare Part B cover Skyrizi instead of Part D?

No. Skyrizi is a self-injected medication that you administer at home, so it is covered under Part D (prescription drugs), not Part B (doctor-administered drugs). If Skyrizi were given by a doctor in an office or clinic, it would be covered under Part B instead, and you would pay a different cost-sharing amount.

Can I use a GoodRx coupon or discount card with Medicare Part D?

You cannot use a GoodRx coupon or other discount card at the same time you use your Medicare Part D coverage. You must choose one or the other. In some cases, paying cash with a discount coupon costs less than your Part D copay, but this is rare with expensive biologics. Ask your pharmacist to price both options before you decide.

What if my doctor prescribes a different dose or frequency than what the prior authorization covers?

If your doctor changes your dose or how often you take Skyrizi, your Part D plan may require a new prior authorization. Your doctor's office will need to submit the updated prescription. This usually takes a few days, so let your doctor know if you need the new dose quickly.

Does Medicare Advantage cover Skyrizi?

Medicare Advantage plans (Part C) include prescription drug coverage, and most cover Skyrizi, but the cost and prior authorization requirements vary by plan. If you have Medicare Advantage, contact your plan directly to find out what you will pay for Skyrizi.