Medicare and Skyrizi: Coverage, cost, and more

You're on Medicare. You've got a prescription for Skyrizi in your hand. And you're sitting there thinking, "Okay but will Medicare actually cover this?"

Maybe you've already flipped through your plan documents, tried calling customer service three times, and still aren't sure. I've been there. Or rather I've sat there, next to people who've been there. And I know how frustrating it feels.

The good news? Yes, Medicare can cover Skyrizi. But before you start celebrating, let's get real it's not as simple as handing over your insurance card and walking away with a free vial. There are rules. Tiers. Paperwork. Costs that can sneak up on you like an overpriced parking meter.

But here's what you need to hear: people just like you are getting Skyrizi through Medicare even with tough conditions like Crohn's, psoriatic arthritis, or severe plaque psoriasis. They're making it work. And guess what? So can you.

Does It Cover?

Let's start with the big question on your mind: Does Medicare actually cover Skyrizi?

Mostly, yes but not through every part of Medicare. That's where things get tricky. Medicare isn't one single plan. It's more like a puzzle, and you've got to pick the right pieces.

Here's the breakdown:

• Part D that's your prescription drug coverage does usually cover Skyrizi.
• Medicare Advantage (Part C) plans that include drug benefits (called MA-PD) also yes, in most cases.
• Part B that's outpatient and doctor visits rarely covers Skyrizi, and only if it's given in a clinical setting like an infusion center.
• Part A hospital insurance nope. Doesn't apply.

So if you want Skyrizi covered, you need either Part D or a Medicare Advantage plan with drug coverage. No way around it.

And here's a little peace of mind: As of 2024, 97% of Medicare Part D plans list Skyrizi on their formulary, according to AbbVie, the drug's manufacturer. That's a really high number for a biologic drug this strong.

But and this is a big "but" being "on formulary" doesn't mean it's cheap. Skyrizi often lands in Tier 5, which is the highest tier for specialty drugs. That means you could still be looking at hundreds per dose at least until you hit the new $2,000 out-of-pocket cap in 2025.

And speaking of cost let's talk numbers.

How Much?

Let me ask you this: Have you seen the list price of Skyrizi lately?

Buckle up. We're talking over $22,000 per dose. That's not a typo. And no, I'm not trying to scare you but it's important to know what we're dealing with. Without insurance, this drug would cost more than a new car over a few years.

But here's the flip side: you won't pay that. Medicare negotiates prices behind the scenes, and your plan sets what you actually see on your bill.

Most people end up paying a copay or coinsurance based on their plan's drug tier. And since Skyrizi is usually Tier 5, that could mean 25% or more of the drug's cost which still adds up fast.

Some folks pay $100 a month. Others are closer to $700. It all depends on your specific plan, whether you're on Extra Help, and where you live.

But something huge is changing in 2025.

Thanks to a new federal law, your out-of-pocket spending on Medicare-covered drugs is capped at $2,000 per year, starting in 2025. That means once you've paid $2,000 total for deductibles, copays, coinsurance you pay nothing for the rest of the year.

Imagine paying $186 a month for 11 months, reaching your cap in November, and then getting your December dose for free. That's not a dream it's the new reality.

But and here's the catch this only applies if Skyrizi is on your plan's formulary. If it's not, you're stuck paying full price, and those costs don't count toward the cap. That's why checking your plan's formulary is non-negotiable.

Scenario	Monthly Cost	Notes
Tier 3 Preferred Brand	~$50$150/month	You pay fixed copay
Tier 5 Specialty Drug	~$300$700/month	Often coinsurance (e.g., 2533% of drug cost)
After $2,000 Cap	$0	Coverage continues, no further charges
Without Part D	Full retail ($22k+/dose)	Not covered without drug plan

How to Qualify?

Okay, so Medicare can cover Skyrizi. But does that mean you'll automatically get it?

Not quite.

Insurance companies don't just hand out six-figure drugs like candy. They want proof and they want to make sure you've tried other options first. That's where things like prior authorization and step therapy come in.

"Wait, I have to try another drug first? Even if my doctor says Skyrizi is best?"

I know. It feels backwards. But this is how most plans work.

For example, if you're being treated for Crohn's disease or ulcerative colitis, many plans like Blue Cross Blue Shield Medicare require documentation that you've tried and failed conventional therapies. That could mean steroids for at least a week, or immunomodulators for two months or more.

And your doctor? They'll need to submit medical records, lab results, maybe a letter explaining why Skyrizi is necessary for you.

It's a hassle. But it's not impossible. In fact, most people who go through the process with their doctor's support do get approved.

What if your plan says no?

You're not out of options. You can file an appeal.

Start by getting the denial in writing. Then, ask your doctor to write a strong letter of medical necessity one that spells out your diagnosis, previous treatments, and why Skyrizi is the right choice.

Submit that to your plan, and don't be shy about following up. Many people win on the first appeal, especially when they have clear clinical evidence on their side.

And if you're between a rock and a hard place while waiting? There's a bridge program but it has limits.

AbbVie's Skyrizi Complete program offers free Skyrizi for up to two years to eligible patients who can't access it due to step therapy issues. But and this is important it's not available for Medicare or Medicaid recipients.

Still, if you're transitioning from a commercial plan to Medicare, this could help cover the gap. It's worth asking your doctor.

Financial Help?

Let's be honest: Even with Medicare, Skyrizi can feel unaffordable. But help exists and I don't just mean "maybe, if you're lucky" help. I mean real, life-changing support.

The biggest one? The federal Extra Help program also known as the Low-Income Subsidy.

If your income is under $22,590 a year (2025 estimate), and your assets are below $17,220, you might qualify. And the benefits are no joke:

• Little or no monthly premium for Part D
• A max of $4.90 for generics
• Just $12.15 for brand-name drugs like Skyrizi that's if you get the full subsidy
• Deductibles and copays slashed

You can apply through the Social Security Extra Help page, call 1-800-772-1213, or visit your local office. It's one of the smartest moves you can make.

But wait there's more.

Over 20 states have their own Pharmaceutical Assistance Programs (SPAPs). These work alongside Medicare to lower drug costs.

Examples include PACENET in Pennsylvania, CalRx in California, and EPIC in New York. Benefits vary, but many offer low copays, annual caps, or enrollment perks for high-cost meds.

For a full list, check the Medicare Interactive SPAP chart it's updated regularly and super easy to read.

And now, one of the most exciting updates in years: The Medicare Prescription Payment Plan (MPPP).

Starting in 2025, if your drug costs are high, you can choose to pay your out-of-pocket costs monthly instead of all at once.

Imagine this: Instead of dropping $2,000 in January, you pay about $167 a month all year. No financial whiplash. No budget panic.

It's automatic for some, but you can enroll through your Part D plan if needed. For someone starting Skyrizi mid-year, this could be a total game-changer.

Comparing Options

Maybe you're wondering: Is Skyrizi worth the hassle compared to other biologics?

That's a fair question. Let's take a quick look at how Skyrizi stacks up against common alternatives.

Drug	Typical Tier	Avg. Medicare Copay	Prior Auth?	Step Therapy?
Skyrizi	5 (Specialty)	$300$700/dose	Yes	Yes
Stelara	45	$250$600/dose	Yes	Yes
Humira	5	$350$800/dose	Yes	Yes
Cosentyx	45	$200$600/dose	Yes	Sometimes
Tremfya	4	$200$500/dose	Yes	Yes

Skyrizi tends to have higher cost-sharing, but it also has one major advantage: it's preferred on more formularies than most. That means better access and smoother approvals in many cases.

Risks to Know

Let's circle back for a second. I've talked a lot about access and cost but what about safety?

Skyrizi is powerful medicine. It works by targeting part of your immune system to reduce inflammation. And while that can be life-changing for autoimmune conditions, it also means your body might not fight infections as well.

Potential risks include:

• Higher chance of infections like tuberculosis or pneumonia
• Rare but serious allergic reactions
• Liver issues which is why your doctor will likely run blood tests before and during treatment
• And no live vaccines while on the drug your doctor will help you plan around that

None of this means you shouldn't take Skyrizi. But it does mean you should talk openly with your doctor, read the fine print, and stay alert to how your body responds.

Your health isn't a form to fill out it's your life. And you get to be in charge.

Final Thoughts

Let's bring it home.

Medicare can cover Skyrizi for psoriasis, psoriatic arthritis, Crohn's, or ulcerative colitis. But it takes more than just a prescription. You'll likely need prior authorization, medical justification, and a plan that includes Skyrizi on its formulary.

The 2025 $2,000 out-of-pocket cap is a game-changer. For the first time, no Medicare beneficiary will have to drain their savings just to stay on a covered medication. That's huge.

And if money is tight? Don't give up. Check if you qualify for Extra Help or a state assistance program. Look into the monthly payment plan. Appeal denials. Get your doctor on your side.

Because at the end of the day, this isn't just about a drug. It's about your comfort. Your mobility. Your ability to show up in life.

So take a deep breath. You're not alone in this. Millions are navigating the same system. And more are succeeding than you think.

Now, here's my challenge to you: Take one step today.

Open your plan documents. Use the Medicare Plan Finder to see if Skyrizi is covered. Call your doctor's office and ask about prior auth. Just one action that's how progress starts.

And when you do, remember: This is your body. Your health. Your right to feel better.

You've got this.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.