Will Medicare Cover Skyrizi? Your Full Guide to Costs and Eligibility

Hey there! If you’ve landed on this page, you’re probably wondering whether Medicare will foot the bill for Skyrizi (risankizumab‑rzaa). The short answer is: yes, it can – but only under the right circumstances. Below, I’ll break everything down in plain‑English, share a few real‑life stories, and give you actionable steps so you can feel confident navigating your coverage.

Medicare Coverage Basics

First things first: Medicare isn’t a single, monolithic program. It’s a toolbox with several parts, and only some of those parts touch prescription drugs.

Original Medicare vs. Part D vs. Medicare Advantage

Part A and Part B cover hospital stays and doctor visits – not most prescription meds. Part D is the stand‑alone prescription‑drug plan many people add to “Original Medicare.” Medicare Advantage (Part C) is an all‑in‑one alternative that often bundles drug coverage.

If you’re on a Part D plan or a Medicare Advantage plan that includes drug benefits, you have a shot at finding Skyrizi on the formulary. Without those, you’ll need a different insurance product – and that’s a whole other story.

What Is a Formulary?

A formulary is simply a list of medicines that a particular plan agrees to cover. Think of it as a restaurant menu: the items on the menu are the drugs you can order; the ones off‑menu are either unavailable or cost‑lier because the plan doesn’t favor them.

Skyrizi is typically placed in Tier 5, the highest tier for most Part D plans. Higher tiers mean higher out‑of‑pocket costs, but they also often come with “preferred” status that can soften the price a bit. The good news? Many plans still label Skyrizi as a preferred tier, which can translate into lower coinsurance.

Sample Formulary Table

Plan Type	Tier for Skyrizi	Preferred?	Typical Coinsurance
Part D – Plan A	5	Yes	25 % until $2,000 OOP
Part D – Plan B	5	No	35 % until $2,000 OOP
Medicare Advantage – Plan C	5	Varies	Varies (often $0 after deductible)

Eligibility Rules

Even if Skyrizi is on your plan’s list, you still need to meet a few eligibility checkpoints.

Medical‑Necessity

Your doctor must certify that Skyrizi is medically necessary for a condition such as:

• Plaque psoriasis
• Psoriatic arthritis
• Crohn’s disease
• Ulcerative colitis

Without that note, the plan will likely deny coverage – a classic “paperwork” snag that can be avoided with a quick chat with your prescriber.

Enrollment Status

You need to be enrolled in a Medicare prescription‑drug plan (Part D) or a Medicare Advantage plan that includes drug benefits. If you’re still on “Original Medicare only,” you’ll have to add a Part D plan during the annual enrollment window (Oct 15 – Dec 7) or qualify for a special enrollment period.

Extra Help (Low‑Income Subsidy)

Low‑income seniors can apply for the Extra Help program, which can lower or even eliminate your Part D premiums, deductibles, and co‑pays. Even a modest reduction can make a $22k‑plus drug feel a little less scary.

How to Check Extra Help Eligibility

Head over to Medicare’s Extra‑Help page, answer a few quick questions about income and assets, and you’ll find out in minutes.

Cost Breakdown

Let’s get into the dollars and cents – the part that makes many of us squint.

Wholesale Acquisition Cost (WAC)

According to the manufacturer, the wholesale cost of one Skyrizi dose in January 2025 was $22,383.49. That’s the “list price” before any insurance discounts.

Typical Out‑of‑Pocket (OOP) Under Part D

Here’s a quick run‑through of the usual Part D cost stages for 2025 (numbers will shift a bit each year):

• Deductible: Up to $590 – you pay the full price until you hit this amount.
• Initial Coverage: 25 % coinsurance on covered drugs (including Skyrizi) until your OOP reaches $2,000.
• Catastrophic Coverage: After $2,000 OOP, you typically pay $0 for the rest of the year. (2026 projected max is $2,100.)

Because Skyrizi sits in Tier 5, the coinsurance can feel steep, but the catastrophic barrier caps your total spend.

Impact of Tier 5 Status

Higher tiers often mean: higher premiums, higher prior‑authorization requirements, and sometimes more paperwork. That said, many Part D plans label Skyrizi as a “preferred” drug, which can shave a few percentage points off the coin‑insurance.

Saving Tools You Can Use Right Now

• Medicare’s Coverage Finder: Input your zip code, select “Prescription drug,” and type “Skyrizi” to see which plans list it.
• AbbVie’s Skyrizi Complete Program: A patient‑assistance program that may provide copay cards or discounts. Reach out directly via their website.
• Pharmacy Discount Cards: Some independent pharmacies offer their own savings plans—always worth asking about.

Check Your Plan

Finding out whether your current plan covers Skyrizi is easier than you think. Here’s a step‑by‑step cheat sheet.

Use Medicare’s Plan Compare Tool

1. Go to Medicare’s Plan Compare.
2. Enter your zip code and select “Prescription drug.”
3. In the search bar, type “Skyrizi.”
4. Review the tier, preferred status, and any prior‑authorization notes.

Call Your Plan’s Customer Service

Sometimes the online tables lag behind. Grab your plan’s phone number (usually on the back of your ID card) and ask these three questions:

• “Is Skyrizi on the formulary?”
• “What tier is it, and what’s the coinsurance?”
• “Do I need prior authorization, and how do I start that process?”

Ask Your Doctor for a Formulary Support Letter

Many insurers will speed up approval if your prescriber sends a brief “medical‑necessity” letter. It’s a quick one‑pager that explains why Skyrizi is the right choice for your specific condition.

Sample Phone Script

“Hi, my name is [Your Name]. I have Medicare Part D plan [Plan Name] and my doctor has prescribed Skyrizi for my psoriasis. Could you confirm if it’s covered, what tier it falls under, and whether a prior‑authorization is required? Thank you!”

Common Pitfalls

Even when everything looks good on paper, a few sneaky pitfalls can trip you up.

Pitfall	Why It Happens	How to Fix It
Plan changes mid‑year	Formularies are updated annually.	Review your plan each October; switch if Skyrizi is dropped.
Missing prior‑authorization	Provider didn’t submit paperwork.	Ask your prescriber to file early and keep a copy.
Assuming $0 premium = $0 drug cost	Premiums and drug tiers are separate.	Check tier and coinsurance before enrollment.
Not using Extra Help	Many seniors forget to apply.	Apply via Medicare.gov and re‑apply if income changes.

Alternative Options

If your plan simply won’t cover Skyrizi—or the out‑of‑pocket cost is still too high—there are alternatives worth exploring.

Other IL‑23 Inhibitors

Drugs like Tremfya (guselkumab) are also IL‑23 blockers. They may sit on a lower tier in some formularies, but effectiveness can vary from person to person.

Traditional Systemic Therapies

Medications such as methotrexate or cyclosporine are older, cheaper, and typically Tier 1 or 2. They might not be as fast‑acting, but for some patients they’re a viable bridge while navigating insurance.

Patient‑Assistance Programs

AbbVie’s “Skyrizi Complete” offers copay cards, and many nonprofit foundations have disease‑specific grants. It’s always worth a quick phone call or website visit.

Real‑World Stories

Numbers and tables are helpful, but hearing from someone who’s walked this path makes it real.

Maria’s Journey – 68 y/o, Medicare Part D, Plaque Psoriasis

Maria was terrified when her dermatologist prescribed Skyrizi; the wholesale price sounded like a “million dollars.” She logged into Medicare’s coverage finder, switched from Plan B to a preferred‑tier Plan A, and qualified for Extra Help. Her annual out‑of‑pocket dropped from $2,500 to $850. “I felt like I finally got my skin back without breaking the bank,” she says.

Dr. Emily Chen, Dermatology Specialist

“Whenever I consider Skyrizi for a patient, the first step is to verify formulary status. I’ve saved countless patients weeks of denial letters by coordinating with their pharmacy and submitting a concise medical‑necessity letter upfront.”

These anecdotes underline a simple truth: proactive communication with your doctor, your plan, and Medicare tools can dramatically change the financial picture.

Takeaway

So, does Medicare cover Skyrizi? Yes—if you’re enrolled in the right drug plan, your doctor confirms medical necessity, and you keep an eye on formulary tiers and prior‑authorization requirements. The biggest levers you control are:

• Choosing the right Part D or Medicare Advantage plan during enrollment.
• Applying for Extra Help if you qualify.
• Working with your prescriber to submit a solid medical‑necessity letter.
• Using Medicare’s coverage finder and the “Skyrizi Complete” assistance program to shrink out‑of‑pocket costs.

Now that you’ve got the roadmap, what’s your next move? Drop a comment below with your experience, or give the Medicare plan‑compare tool a spin and let us know what you find. If you have more questions, I’m just a click away—let’s tackle this together!