Medicare covers immunotherapy treatment for cancer. Out-of-pocket costs will vary, depending on the Medicare plan a person has and whether or not they have supplemental insurance.
If a person has original Medicare, the costs involve a 20% coinsurance after paying the deductible. For an individual with a Medicare Advantage plan, the costs include copays and deductibles, which vary with the plan.
This article provides an overview of immunotherapy, the types available, and what to expect during treatment. It also examines Medicare coverage and the costs associated with immunotherapy and lists some programs that can help people with limited means pay the costs.
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.
Immunotherapy is a form of biological therapy that uses substances from living organisms to treat cancer. It works by boosting the function of a person’s immune system, which fights infections and disease.
When the immune system functions optimally, it detects and destroys abnormal cells, which helps prevent and suppress the growth of many cancers. Immunotherapy helps strengthen the immune system against cancer.
Healthcare professionals put immunotherapy drugs into one of several classes, depending on how they interact with the immune system.
The following sections will look at types of immunotherapy in more detail.
T cell transfer therapy
T cell transfer therapy improves the natural ability of T cells to fight cancer.
Healthcare professionals remove T cells from a person’s tumor and determine which ones are most active against the cancer.
Scientists will then cultivate cells in a laboratory before a healthcare professional injects them into the person’s vein.
Immune checkpoint inhibitors
These drugs block immune system checkpoints, which are structures that prevent an overly strong immune response. This action permits immune cells to respond more effectively against cancer.
Monoclonal antibodies are immune system proteins that scientists create in a laboratory to bind to certain targets on cancer cells.
Some of these antibodies mark cancer cells to help the immune system recognize them, which increases the likelihood of cancer cell destruction.
Immune system modulators
Immune system modulators improve the body’s immune response when fighting cancer. Some of these drugs target the immune system generally, while others affect specific parts of it.
Treatment vaccines help the immune system recognize the antigens in cancer cells and strengthen the body’s natural response against the cells.
Some cancer drugs may suppress white blood cells. These are a part of the immune system that enables a person to fight infections. A lower count of white blood cells may weaken the body’s infection-fighting response.
Immunotherapy comes in different forms, including:
- oral drugs, which people swallow
- intravenous drugs, which healthcare professionals administer into people’s veins
- topical drugs, which people apply to the skin
- intravesical drugs, which healthcare professionals direct toward the bladder
Healthcare professionals provide immunotherapy treatment in a clinic, doctor’s office, or outpatient hospital unit. The frequency can be daily, weekly, or monthly, and the duration varies with the medication and type of cancer the person has.
They will monitor the treatment’s effectiveness by running examinations, blood tests, and scans.
This type of treatment may cause side effects, such as pain, swelling, and flushing at the injection site. This will likely be because the boosted immune system attacks both healthy tissue and cancerous cells.
Medicare is the federal insurance program for people aged 65 years and older, as well as younger individuals with certain disabilities or conditions.
Each part of Medicare provides coverage for immunotherapy drugs. The sections below will look at Medicare coverage for immunotherapy in more detail.
Original Medicare consists of Part A, which is hospitalization insurance, and Part B, which is medical insurance. Part A covers a hospital stay, meals, and any medications a person receives as an inpatient, including immunotherapy treatment.
Part B covers outpatient care, such as doctor visits and radiation treatment. People often receive intravenous immunotherapy in a doctor’s office or clinic, so many immunotherapy services fall under Part B. Medicare may also cover some oral immunotherapy drugs under Part B.
Medicare Advantage, or Medicare Part C, is the alternative to original Medicare. It provides the same benefits, including coverage for immunotherapy treatment during a hospital stay and in a doctor’s office.
Many Medicare Advantage plans also include prescription drug coverage, so if a person needs an immunotherapy drug that Part B does not cover, their Medicare Advantage plan may help pay for the drug.
Part D is Medicare prescription drug coverage available only to people enrolled in original Medicare. It covers medications a person takes at home. Each plan has a list of covered drugs, which includes medications in the commonly prescribed classes.
Part D also covers some chemotherapy drugs, and it may cover an immunotherapy treatment that does not fall under Part B coverage. Part D plans also cover other drugs prescribed for people with cancer, such as those to relieve nausea or pain.
However, it does not help pay for medications that people take at home.
Each part of Medicare has some out-of-pocket costs. The following sections will look at these in more detail.
Part A costs in 2021 include a $1,484 deductible per benefit period and a 0% coinsurance for days 1–60 per benefit period.
Part B costs in 2021 include:
- a $203 annual deductible
- a 20% coinsurance
- a $148.50 monthly premium
Medicare Advantage plan costs include deductibles, copays, coinsurance, and monthly premiums. These expenses vary among plans.
Part D costs for immunotherapy treatment include deductibles, copays, coinsurance, and monthly premiums. These vary with the plan, the medications, and whether a person uses generic or brand-name drugs.
The only Medigap cost is the premium, which may vary from under $100 to several hundred dollars per month.
Examples of costs
To provide an idea of immunotherapy expenses, the sections below show the costs for two medications, including the list price.
However, the price a person pays will depend on various factors, including their plan, their pharmacy, and their location.
According to the manufacturer, Merck, the list price of a 200-milligram dose of Keytruda, when received once every 3 weeks, is $9,869.94.
However, different people pay different amounts, depending on their plan. For example:
- Medicare Advantage: Around 41% of people enrolled in a Medicare Advantage plan did not pay any out-of-pocket costs for this drug. Of those who did pay out-of-pocket costs, 80% paid between $0 and $925 per infusion, after paying the deductible.
- Original Medicare: Around 80% of people enrolled in original Medicare paid between $1,000 and $1,950 per infusion, after paying the deductible.
The manufacturer may offer financial help through the Merck Access Program, which a person can contact by calling 855-257-3932.
The manufacturer, Amgen, report that the list price for a dose of Neulasta is $6,231.
However, in 2018, a person paid different amounts, depending on their plan. For example:
- Medicare Advantage: Around 62% of people enrolled in a Medicare Advantage plan paid less than $5 per dose. Of the remaining percentage, 38% paid an average price of $748 per dose.
- Original Medicare: Around 46% of people enrolled in original Medicare paid less than $5 per dose. Of the remaining percentage, 54% paid an average price of $908 per dose.
The Amgen First Step Program may provide financial assistance, and a person can contact this program by calling 888-657-8371.
Some programs may help people with limited means pay their out-of-pocket costs. These programs include:
- Medicaid. This is a federal-state program that pays much of someone’s Medicare costs.
- Medicare savings programs. These provide assistance with various costs. Three of the programs help pay a monthly premium, while one program helps pay most out-of-pocket Medicare costs.
- Extra Help. This provides approximately $5,000 worth of assistance per year in paying Part D costs.
Medicare out-of-pocket costs for immunotherapy can be expensive. Medigap, plus several other programs, can provide assistance with the costs.