Skyrizi Medicare Coverage

Skyrizi is a prescription medication that many people use to treat moderate to severe plaque psoriasis and other conditions like Crohn’s disease. As a Medicare Advisor at Medicare Advisors Insurance Group LLC I’m here to break down how Skyrizi works with Medicare coverage. We’ll go over what it is how it can be covered and some tips on what to look out for.

What is Skyrizi?

Skyrizi (risankizumab-rzaa) is an injectable biologic medication that helps people with certain inflammatory conditions. Skyrizi works by targeting a specific protein in the body called interleukin-23 (IL-23) which is involved in the inflammatory process. By blocking IL-23 Skyrizi helps to reduce inflammation and keep symptoms under control.

How Skyrizi is Administered

• Skyrizi is typically administered as an injection under the skin
• The initial dose is given at weeks 0 and 4
• Maintenance doses are administered every 12 weeks after that

This schedule makes it easier for patients to manage their treatment but let’s be real who likes needles right? At least it’s not every week!

Potential Side Effects

• Infections (since it can lower your immune response)
• Injection site reactions
• Fatigue

Just like any medication Skyrizi has its side effects. I mean who wouldn’t enjoy a little fatigue and potential infections? Just kidding but it’s crucial to discuss these with your healthcare provider.

Does Medicare Cover Skyrizi?

Medicare coverage for Skyrizi can be a bit complicated. Coverage depends on the type of Medicare you have (Original Medicare or a Medicare Advantage plan) and your specific plan details.

Coverage Under Original Medicare (Parts A and B)

• Medicare Part A: Skyrizi isn’t covered under Medicare Part A since this part covers hospital inpatient care. So unless you plan on moving into a hospital every time you need a dose it’s a no-go here.
• Medicare Part B: Skyrizi can be covered under Part B but only if it’s administered in a doctor’s office or a clinical setting as part of outpatient care. This usually means you’ll pay 20% of the Medicare-approved amount after you meet your deductible.

Medicare Part D: Prescription Drug Coverage

• Most Medicare Part D plans may cover Skyrizi under their specialty drug tier
• Coverage depends on your specific Part D plan’s formulary

Skyrizi can also be covered under Medicare Part D which is the part of Medicare that covers prescription drugs. Since Skyrizi is a specialty medication it’s usually found on the higher tier of a Part D formulary. This means it could come with a higher copayment or coinsurance.

Medicare Advantage (Part C) Plans

Medicare Advantage plans are offered by private insurance companies and must cover at least the same benefits as Original Medicare. Many Medicare Advantage plans also include prescription drug coverage which may cover Skyrizi.

• Check your specific plan’s formulary to see if Skyrizi is covered
• Ask about any prior authorization requirements (some plans may require your doctor to get approval before the plan will cover Skyrizi)

The Reality of Medicare Advantage

“While Medicare Advantage plans can offer additional benefits the reality is not all plans are created equal” says Henry Beltran owner of Medicare Advisors Insurance Group LLC. “It’s like choosing between an all-you-can-eat buffet and a salad bar. You gotta know what you’re getting.”

Cost Considerations for Skyrizi

Skyrizi isn’t cheap let’s put that out there. Depending on your insurance plan your costs for Skyrizi can vary widely. Here’s what to keep in mind:

1. Deductibles and Coinsurance: If you’re under Part B you’ll need to pay the Part B deductible first then 20% of the Medicare-approved amount.
2. Part D Costs: For those with Part D plans your costs will depend on your plan’s formulary and your pharmacy. You’ll likely face a high copay or coinsurance due to Skyrizi being a specialty drug.
3. Out-of-Pocket Maximums: Medicare Advantage plans often have out-of-pocket maximums which could limit how much you’ll pay for Skyrizi in a year.

Skyrizi Savings Programs

• Manufacturer Coupons: AbbVie the manufacturer of Skyrizi often offers savings programs or coupons to help reduce the cost for eligible patients.
• Patient Assistance Programs: For those without sufficient coverage or in financial need patient assistance programs may be available.

Conclusion: Is Skyrizi Right for You?

Navigating Medicare coverage for Skyrizi can feel like you’re trying to find a parking spot at a rock concert. It’s tough but not impossible. “We always advise our clients to look at all their options carefully and not just go with the first plan they see” says Henry Beltran. “Think of it as shopping for a car. You wouldn’t just buy the first one you see at the lot would you?”

Key Takeaways:

• Skyrizi is covered under Medicare Part B and Part D but you must check the specific requirements
• Medicare Advantage plans can also cover Skyrizi but it varies by plan
• Out-of-pocket costs can be significant but savings programs may help

Choosing the right coverage for Skyrizi under Medicare is important. It’s about finding the balance between cost and coverage that fits your needs. As always consulting with a Medicare Advisor can help you make the best decision for your health and your wallet.

Frequently Asked Questions

What is the difference between Medicare Part B and Part D when it comes to Skyrizi?

Part B covers Skyrizi if administered in a clinical setting while Part D may cover it under prescription drug plans for self-administration.

Can I switch my Medicare plan if Skyrizi isn’t covered?

Yes during the Medicare Open Enrollment Period (October 15 to December 7) you can switch plans to find one that offers the coverage you need.

How can I get help paying for Skyrizi if I have Medicare?

Look into savings programs offered by the manufacturer or patient assistance programs that can provide financial aid based on eligibility.

This information is brought to you by Medicare Advisors Insurance Group LLC your trusted partner in navigating Medicare coverage. For more information or personalized advice feel free to reach out to us!