Medicare Part B covers Skyrizi, but only for specific skin conditions and only when your doctor documents that other treatments have not worked

Skyrizi (risankizumab) is a biologic drug used to treat moderate to severe plaque psoriasis, Crohn's disease, and ulcerative colitis. Medicare Part B does cover it, but the coverage comes with conditions. Your doctor must show that you have tried and failed on other treatments first — a requirement called a prior authorization. Without that approval from Medicare, the drug will not be covered, and you will pay the full cost out of pocket.

The coverage rules are the same whether you have Original Medicare or a Medicare Advantage plan, though Advantage plans may have different copays or deductibles. The real barrier is not whether Medicare covers the drug — it does — but whether your specific medical history meets the criteria Medicare uses to decide when to pay for it.

Key Takeaways

  • Medicare Part B covers Skyrizi for plaque psoriasis, Crohn's disease, and ulcerative colitis, but your doctor must request prior authorization before you start the drug.
  • Prior authorization requires documentation that you have used and failed on at least one other biologic or conventional treatment for your condition.
  • Your rheumatologist, dermatologist, or gastroenterologist submits the prior authorization request to Medicare — you do not do this yourself.
  • If Medicare denies the request, you have the right to appeal, and your doctor can submit additional medical records to support the appeal.
  • The copay for Skyrizi under Part B is typically 20 percent of the approved amount after you meet your deductible, but costs vary by plan and location.

What Medicare Part B requires before covering Skyrizi

Medicare does not cover Skyrizi on the first visit. Your doctor must show that you have already tried other treatments and that they did not work well enough or caused side effects you could not tolerate. For plaque psoriasis, this usually means you have used topical steroids or phototherapy and they did not clear your skin. For Crohn's disease or ulcerative colitis, it means you have tried conventional treatments like mesalamine or corticosteroids, or another biologic like infliximab or adalimumab.

Your doctor gathers your medical records, documents your current symptoms, and writes a letter to Medicare explaining why Skyrizi is medically necessary for you. This is the prior authorization request. Medicare reviews it within 72 hours in most cases. If Medicare agrees that you meet the criteria, it sends approval to your doctor's office, and you can start the drug. If Medicare denies it, your doctor can appeal by submitting more detailed records or a letter from a specialist explaining why other options will not work for you.

How to start the prior authorization process with your doctor

You do not contact Medicare directly to request prior authorization. Instead, you tell your doctor that you want to discuss Skyrizi as a treatment option. Your doctor's office — usually the nurse or medical assistant — handles the entire prior authorization request. They will ask you for permission to send your medical records to Medicare, then submit the request on your behalf.

Before your appointment, gather any records from previous treatments: dates you used them, how long you used them, and whether they worked or caused problems. Bring these to your visit. Your doctor will review them and decide whether to submit the prior authorization request. If your doctor agrees that Skyrizi is appropriate for you, the office will submit the request within a few days. You should hear back within one to two weeks in most cases.

If your doctor's office says they need more information from you — such as dates of previous treatments or names of medications you have taken — provide it as soon as you can. Delays in getting this information to them delay the prior authorization decision.

What happens if Medicare denies the prior authorization

If Medicare denies the request, your doctor can appeal. The appeal process allows your doctor to submit additional medical records, test results, or a detailed letter explaining why other treatments are not suitable for you. This is not a formal court process — it is a review by a Medicare medical reviewer who looks at the new information your doctor provides.

Appeals usually take two to four weeks. Your doctor's office will handle the appeal for you; you do not need to contact Medicare yourself. If the appeal is also denied, you have the right to request a hearing before an administrative law judge, but this is rare and usually only happens if your doctor believes Medicare made a clear error in reviewing your medical records.

Your out-of-pocket costs for Skyrizi under Part B

Once Medicare approves Skyrizi, you pay 20 percent of the Medicare-approved amount after you meet your Part B deductible. The deductible for 2024 is $240, but this amount changes each year. The actual cost of Skyrizi varies depending on the dose and how often you receive it — some patients get injections every four weeks, others every eight weeks.

If you have a Medigap policy (supplemental insurance), it may cover some or all of your 20 percent copay, depending on which Medigap plan you have. If you have a Medicare Advantage plan instead of Original Medicare, your copay may be different — some Advantage plans charge a flat copay per injection, while others use coinsurance like Original Medicare. Check your plan documents or call your plan's customer service to find out your exact copay.

If the cost is a burden, ask your doctor's office whether Janssen (the manufacturer of Skyrizi) offers a patient information program. These programs can reduce or eliminate your copay if your income is below a certain level.

Skyrizi versus other biologic options Medicare covers

Medicare covers many other biologic drugs for the same conditions as Skyrizi. For plaque psoriasis, alternatives include dupilumab (Dupixent), secukinumab (Cosentyx), and ixekizumab (Taltz). For Crohn's disease and ulcerative colitis, options include infliximab (Remicade), adalimumab (Humira), and vedolizumab (Entyvio). Your doctor chooses which biologic to try based on your medical history, other health conditions, and how well you tolerate the drug.

If your doctor prescribes a different biologic first and it does not work, Medicare will cover Skyrizi as a second-line option without requiring you to try additional drugs. The prior authorization process is the same — your doctor submits documentation that the first biologic failed, and Medicare reviews it.

How to check your coverage before starting treatment

You can call Medicare directly at 1-800-MEDICARE (1-800-633-4227) and ask whether Skyrizi is covered under your plan. Have your Medicare number ready. Medicare can tell you whether the drug is on the formulary (the list of covered drugs) and what your copay will be, but they cannot tell you whether you personally will be approved until your doctor submits the prior authorization request.

If you have a Medicare Advantage plan, call your plan's customer service number instead of Medicare. Your plan's customer service team can tell you the copay and whether prior authorization is required. They can also tell you which doctors in your network are authorized to prescribe Skyrizi.

Frequently Asked Questions

Can I start Skyrizi while waiting for prior authorization approval?

No. Your doctor will not prescribe it, and the pharmacy will not fill it, until Medicare approves the prior authorization. If you need treatment urgently, ask your doctor whether another drug that does not require prior authorization might work for you temporarily.

What if my doctor says I do not need to try other treatments first?

Your doctor's opinion does not override Medicare's rules. Medicare requires documentation of prior treatment failure before covering Skyrizi. If your doctor believes you should not use other treatments due to allergies or serious side effects, they can explain this in the prior authorization request, and Medicare will review it.

Does Medicare Part D cover Skyrizi instead of Part B?

No. Skyrizi is a biologic drug given by injection, so it is covered under Part B, not Part D. Part D covers oral medications you take at home. Your Part B deductible and copay explore, not your Part D costs.

If I switch from Original Medicare to a Medicare Advantage plan, will my Skyrizi coverage continue?

Coverage may continue, but the copay and prior authorization rules may be different. Contact your new Advantage plan before the switch to confirm that Skyrizi is covered and what your copay will be. If your new plan does not cover it, you may be able to switch back to Original Medicare during the annual open enrollment period.

What should I do if the pharmacy says Medicare denied my claim?

Call your doctor's office when ready. The denial may be a billing error, or it may mean the prior authorization expired or was not submitted correctly. Your doctor's office can contact Medicare to find out why the claim was denied and resubmit if needed.