How Medicare Part B covers Cosentyx

Medicare Part B covers Cosentyx (secukinumab), a biologic medication used to treat psoriasis, psoriatic arthritis, ankylosing spondylitis, and other inflammatory conditions. Part B pays for Cosentyx when it is administered by injection in a doctor's office or hospital outpatient setting, and when your doctor determines it is medically necessary for your condition.

The coverage depends on how the drug is given. If you receive Cosentyx as an injection at your rheumatologist's office or an outpatient clinic, Medicare Part B typically covers it. If you take it at home using a self-injection pen, coverage may shift to Part D (prescription drug coverage) instead, depending on your plan. This distinction matters because your out-of-pocket costs will differ.

Like all Part B services, you will pay a coinsurance amount after you meet your Part B deductible. In 2024, the Part B deductible is $240 per year, though this amount changes annually. After you meet the deductible, you typically pay 20 percent of the Medicare-approved amount for the drug.

Key Takeaways

  • Medicare Part B covers Cosentyx when administered by a healthcare provider in an office or outpatient setting, but self-injections at home may be covered under Part D instead.
  • You pay 20 percent coinsurance after meeting your annual Part B deductible, which was $240 in 2024.
  • Your actual out-of-pocket cost depends on whether your plan has a supplemental policy (Medigap) or if you are in a Medicare Advantage plan with different cost rules.
  • Your doctor must document that Cosentyx is medically necessary for your specific condition before Medicare will cover it.
  • Cosentyx manufacturers offer copay information programs that may reduce your share of the cost.

When Part B covers Cosentyx versus Part D

The setting where you receive Cosentyx determines which part of Medicare pays. Part B covers office-administered injections — meaning your rheumatologist or nurse gives you the shot in a medical office, clinic, or hospital outpatient department. In this case, the drug and the administration are both billed to Part B.

If you use a Cosentyx self-injection pen at home, the coverage typically falls under Part D, your prescription drug plan. This is because self-administered drugs are generally considered Part D benefits, even if they are injections. Some Medicare Advantage plans may handle this differently, so check your plan documents or call your plan's customer service line to confirm.

This matters for your wallet. Part B coinsurance (20 percent after the deductible) is often lower than Part D copays or coinsurance, especially for expensive biologics. However, if you have a Medigap supplemental policy, it may cover your Part B coinsurance, making office visits very affordable. Part D coverage varies by plan and tier, and you may face higher costs during the coverage gap phase.

What you pay out of pocket

Your costs depend on your specific Medicare coverage type. If you have Original Medicare plus a Medigap policy, Medigap typically covers your 20 percent Part B coinsurance after the deductible, so your out-of-pocket cost for an office-administered Cosentyx injection may be minimal or zero.

If you have Original Medicare without Medigap, you pay the full 20 percent coinsurance after meeting the $240 annual Part B deductible. For a drug like Cosentyx, which can cost several thousand dollars per dose, this coinsurance can be substantial — potentially hundreds of dollars per injection depending on the Medicare-approved amount.

If you have a Medicare Advantage plan, your costs work differently. These plans set their own copays and coinsurance amounts, which vary by plan and by whether the drug is administered in-office or self-injected. Some plans may require prior authorization before covering Cosentyx, meaning your doctor must request approval first. Contact your plan directly to learn your specific copay amount.

For self-injected Cosentyx covered under Part D, you will pay according to your plan's formulary tier. Most plans place Cosentyx on a higher tier, which means higher copays or coinsurance. You may also face a coverage gap (the "donut hole") if your total drug spending reaches a certain threshold, though catastrophic coverage kicks in after that.

Prior authorization and medical necessity

Medicare requires prior authorization for Cosentyx in many cases. This means your doctor must submit documentation to Medicare (or your Medicare Advantage plan) showing that Cosentyx is medically necessary for your condition before the drug will be covered. Your doctor's office typically handles this step, but it can add one to two weeks to the process.

Medicare will approve Cosentyx if your diagnosis matches one of the FDA-approved uses — psoriasis, psoriatic arthritis, ankylosing spondylitis, non-radiographic axial spondyloarthritis, or certain other inflammatory conditions — and if you have tried or cannot tolerate other treatments first. Some plans require you to fail a less expensive medication before approving Cosentyx.

If Medicare denies coverage, your doctor can appeal the decision. The appeal process takes time, so ask your doctor's office about the timeline and what documentation they will submit to support the appeal.

Copay information programs

The manufacturer of Cosentyx, Novartis, offers a copay information program that may reduce your out-of-pocket costs. This program can help cover coinsurance, copays, and deductibles for patients with Medicare, Medicaid, or private insurance. may be able to access patients may pay as little as $0 to $50 per month for Cosentyx, depending on their income and insurance type.

To learn about the program and check your may be able to access, visit the Novartis patient information website or call their support line. You will need to provide information about your income and insurance coverage. Your doctor's office can also help you enroll. These programs are separate from Medicare and do not count toward your deductible or out-of-pocket maximum.

Medicare Advantage plans and Cosentyx

If you are enrolled in a Medicare Advantage plan, coverage for Cosentyx works differently than Original Medicare. Each plan decides whether to cover Cosentyx, at what tier, and with what copay or coinsurance. Some plans may not cover it at all, or may require you to try other drugs first.

Before starting Cosentyx, contact your Medicare Advantage plan to confirm coverage. Ask whether the drug is on the formulary, what your copay or coinsurance will be, whether prior authorization is required, and whether the plan covers office-administered injections, self-injections, or both. Plans change their formularies each year, so even if Cosentyx was covered last year, verify coverage for the current year.

If your plan does not cover Cosentyx or the cost is too high, you have options. You can request a formulary exception from your plan, asking them to cover the drug even if it is not on the formulary. Your doctor must submit a letter explaining why Cosentyx is medically necessary for you. Some plans approve these requests, especially if you have tried other medications without success.

Switching from commercial insurance to Medicare

If you are currently taking Cosentyx on a commercial insurance plan and are turning 65 or becoming Medicare-may be able to access, plan ahead for the transition. Your commercial plan may cover self-injections at home with a lower copay than Medicare Part D will. Once you switch to Medicare, your coverage and costs may change significantly.

Talk to your doctor and your Medicare plan before your coverage switches. Ask whether your new plan covers Cosentyx and at what cost. If the cost will be much higher, explore whether switching to office-administered injections (covered by Part B) would be more affordable. Some patients find that the combination of Original Medicare plus Medigap makes office-administered biologics very affordable, even if self-injection was cheaper on their old commercial plan.

Frequently Asked Questions

Does Medicare Part B cover Cosentyx pens I use at home?

No. Medicare Part B covers Cosentyx only when a healthcare provider administers it in an office or outpatient setting. Self-injections at home are typically covered under Part D (prescription drug coverage) instead. Check your specific Medicare Advantage plan, as some may have different rules.

What if my doctor says I need Cosentyx but Medicare denies it?

Your doctor can appeal the denial by submitting additional medical documentation explaining why Cosentyx is necessary for your condition. The appeal process usually takes two to four weeks. Ask your doctor's office about the timeline and what they will include in the appeal.

Will the Novartis copay information program work with Medicare?

Yes. Novartis offers copay information for Medicare patients. The program can help cover your coinsurance, copays, and deductibles. may be able to access patients may pay $0 to $50 per month. Contact Novartis directly or ask your doctor's office to help you enroll.

How much will I pay for Cosentyx under Medicare Part B?

After you meet your $240 annual Part B deductible, you pay 20 percent coinsurance on the Medicare-approved amount. If you have Medigap coverage, your supplemental plan typically covers this coinsurance. If you have a Medicare Advantage plan, your copay or coinsurance depends on your specific plan.

Can I switch from self-injections to office visits to lower my costs?

Yes. If Part D coverage is expensive, ask your doctor whether office-administered Cosentyx is an option. Office visits are covered by Part B, and if you have Medigap, your coinsurance may be fully covered, making this route much cheaper than Part D self-injections.