Medicare Part B may help with the costs of Keytruda. Outpatient facilities usually administer the drug intravenously, and Part B covers outpatient services.
The generic name for Keytruda is pembrolizumab. Doctors may prescribe this medication to treat certain cancers, including melanoma, non-small cell lung cancer, and certain types of bladder, gastric, and cervical cell cancers.
Since Keytruda requires an intravenous (IV) infusion, Medicare Part B will usually help with the costs. Part B covers outpatient medical care.
This article will further describe how Medicare Part B pays for Keytruda and the out-of-pocket expenses a person may expect.
Glossary of Medicare terms
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare will usually cover Keytruda under Part B, and it may request that a doctor confirm that the medication is medically necessary.
A person may need to pay out-of-pocket costs, such as coinsurance, deductibles, and copayments, depending on their insurance type.
Costs related to Keytruda coverage often depend on a person’s Medicare plan. The list price for one Keytruda infusion every three weeks is $11,337.36, according to Keytruda manufacturers.
Medicare may decline coverage for Keytruda if a doctor prescribes the medication at a higher dosage than the Food and Drug Administration (FDA) label recommends.
Learn more about Medicare coverage for cancer treatments.
The different parts of Medicare provide different coverage options and have different rules.
Original Medicare
With Original Medicare, Part A and Part B benefits are billed by Medicare directly.
As Keytruda is an IV infusion and not a medication that a person can self-administer, Medicare Part B may help cover up to 80% of the treatment costs.
Part B covers medical services, including doctor’s visits, durable medical equipment, and some medications, like Keytruda.
First, a person must meet their Part B deductible, which is $240 in 2024. If they have paid their Part B deductible, they are responsible for paying a 20% coinsurance.
According to the Keytruda manufacturers, the average person with Original Medicare and no supplemental insurance coverage will pay between $1,300 and $2,100 for each Keytruda infusion after meeting their deductible.
Medicare Advantage (Part C) is an alternative to Original Medicare. Private insurance companies administer Medicare Advantage plans. These plans combine Part A, Part B, and sometimes Part D prescription drug benefits.
Numerous region-specific Medicare Advantage plans exist. Each has different out-of-pocket expenses. This also makes predicting how much Keytruda will cost more difficult.
An estimated 38% of people with Medicare Advantage did not pay any out-of-pocket costs for their Keytruda, according to Keytruda manufacturers.
Of patients who did pay out-of-pocket costs and met their deductible, Keytruda cost between $0.01 and $925 per infusion.
To obtain the best cost estimate, a person may find it useful to reach out to their Medicare Advantage plan provider and ask how much they may pay for Keytruda. The insurer should review a person’s deductible and coverage to provide a more realistic cost estimate.
Medicare supplement insurance
If a person has Medicare supplement insurance, also known as a Medigap plan, their costs for Keytruda may be less, depending on their policy.
If a Medigap plan covers the Part B coinsurance, the 20% charge relating to the drug may be covered. This means a person could pay zero dollars for their treatment after the deductible has been paid.
An individual may have a high deductible Medigap plan, in which they must spend more than $2,800 before their plan pays for treatment. In this instance, the Medigap plan would not pay the 20% coinsurance until a person has paid the deductible in full.
If a person’s doctor recommends Keytruda but their Medicare benefits indicate Keytruda will be costly, the individual may have other options to receive financial help. One such option is Medicaid.
Medicaid is a state-funded program that provides extra financial help for medical benefits. Qualifying for Medicaid is based on need, which means a person must be within the required income levels to qualify.
According to the Keytruda website, people with Medicaid typically pay between $4 and $8 for their Keytruda infusion.
For more information, a person can visit www.medicaid.gov.
Keytruda is one example of a PD-1/PD-L1 inhibitor, but there are others. Each works in a slightly different way to target the PD-1 protein. Examples of other similar medications
Doctors may prescribe each medication based on the type of cancer a person has, as well as if they have received any other forms of treatment, such as chemotherapy or radiation.
Does Medicare cover other treatments?
Most medical alternatives to Keytruda are also available via intravenous infusion, and Part B may cover them.
While the drugs may be alternative options, there is no guarantee they will be less expensive than Keytruda, and sometimes Medicare will decline coverage if they question the suitability of the drug.
Keytruda is a medication that belongs to the monoclonal antibodies drug class.
It is an immunotherapy drug, which means the medication acts on a person’s immune system to help fight off cancer cells and reduce the ability of the cancer cells to multiply.
Doctors classify it as a PD-1/PD-L1 inhibitor because it targets PD-1 proteins in immune system cells.
Doctors prescribe Keytruda for administration by IV infusion. A doctor may recommend receiving Keytruda at an infusion center or at their office.
Learn about Medicare and immunotherapy.
Is Keytruda covered under Part B?
Medicare Part B may cover some of the costs of Keytruda. Part B covers infusions when a medical professional administers them.
What is the monthly cost of Keytruda?
How much a person pays per month for Keytruda can depend on their health insurance plan.
The list price for one dose when a person requires Keytruda every 3 weeks is $11,337.36, according to the Keytruda website. If a person requires Keytruda every six weeks, the list price is $22,674.72.
Most individuals do not pay the list price, but they may still have some out-of-pocket costs.
Is immunotherapy for cancer covered by Medicare?
Medicare may cover immunotherapy for cancer. However, out-of-pocket costs may still apply, depending on a person’s plan.
For how long will Medicare pay for immunotherapy?
How long Medicare will pay for immunotherapy can vary. In some cases, it may cover the cost of the whole treatment.
However, each Medicare plan has a formulary, which is a list of drugs that it covers. Each formulary must have at least two drugs within the drug class, but the specific drugs may be subject to change. If a person is receiving Medicare coverage for a specific immunotherapy drug, and the drug is then no longer on the formulary while they are still receiving treatment, they are able to appeal for an exception to continue receiving Medicare coverage for that specific drug.
Medicare will usually help pay for Keytruda expenses under Medicare Part B.
Out-of-pocket expenses may vary based on the type of insurance a person has, including Medigap or Medicare Advantage.
Programs such as Medicaid are available to help a person pay for their Keytruda to reduce out-of-pocket expenses.