Keytruda is often prescribed by doctors to treat specific forms of cancer. Medicare Part B may help with the costs of Keytruda, as outpatient facilities usually administer the drug intravenously.
The generic name for Keytruda is pembrolizumab, and because the medication requires an intravenous infusion, Medicare Part B, which covers outpatient medical care, will usually help with the costs.
This article will further describe how Medicare Part B pays for Keytruda and the out-of-pocket expenses a person may expect.
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 they may request that a doctor confirm that the medication is medically necessary.
A person may be required to pay out-of-pocket costs, such as coinsurance, deductibles, and copayments, depending upon their insurance type.
Costs related to Keytruda coverage often depend upon a person’s Medicare plan. The list price for one Keytruda infusion is $9,724.08, according to Keytruda manufacturers.
Medicare may decline cover for Keytruda if a doctor prescribes the medicine at a higher dose than the FDA label recommends.
The different parts of Medicare provide different coverage options and have different rules.
With original Medicare, a person’s Part A and Part B benefits are billed by Medicare directly.
Because Keytruda is an intravenous infusion and not a medicine that a person can self-administer, Medicare Part B will help pay for the drug.
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 was $203 in 2021. If a person has 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 $1,000 and $1,950 per Keytruda infusion after meeting their deductible.
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, meaning 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 $2,000 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.
Medicare Advantage is an alternative to original Medicare. Private insurance companies administer Medicare Advantage plans, which combine Part A, Part B, and sometimes Part D prescription drug benefits.
There are numerous, region-specific Medicare Advantage plans and each has different out-of-pocket expenses. This also makes predicting how much Keytruda will cost more difficult.
An estimated 41% 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 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.
Keytruda is a medication that belongs to the monoclonal antibodies drug class.
It is an immunotherapy drug, which means the medicine acts on a person’s immune system to help fight off cancer cells and reduce cancer cells’ abilities to multiply.
Doctors classify it as a PD-1/PD-L1 inhibitor because it targets PD-1 proteins on immune system cells.
How it is used
Doctors prescribe Keytruda for administration by intravenous infusion. A doctor may recommend receiving Keytruda at an infusion center or at their office.
The medication usually infuses over 30 minutes. Most people will receive infusions every three weeks at a duration their doctor prescribes.
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 include:
- nivolumab, also known as Opdivo
- atezolizumab, also known as Tecentriq
- durvalumab, also known as Imfinzi
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.
Are alternatives covered?
Most medical alternatives to Keytruda are also available via intravenous infusion, and Part B will typically cover them.
While the drugs may be alternatives, there is no guarantee they will be less expensive than Keytruda, and sometimes Medicare will decline coverage if they question the suitability of the prescribed drug.
For example, according to GoodRx, Opdivo is not usually eligible for coverage under Medicare, but if it is, a typical out-of-pocket expense could be $7,568.
If a person’s doctor recommends Keytruda and their Medicare benefits indicate Keytruda will be costly, there are other ways a person may be able to receive financial help.
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 parameters to qualify.
According to the Keytruda website, those with Medicaid typically pay between $4 and $8 for their Keytruda infusion.
For more information, a person can visit www.Medicaid.gov.
Medicare will usually cover Keytruda expenses under Part B, which means a person would not need to look at a formulary to confirm coverage.
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.