- Keytruda (pembrolizumab) is an FDA-approved immunotherapy treatment for cancer.
- Medicare Part B covers Keytruda infusions as an outpatient prescription drug when it is used in the treatment of certain cancers.
- After you’ve paid your Part B deductible, Medicare beneficiaries will owe a 20-percent coinsurance cost for Keytruda.
Keytruda is a newer immunotherapy drug that has been FDA-approved to treat several types of cancer, such as melanoma and lung cancer.
With the initial success of this new treatment option, many Medicare beneficiaries may be wondering if this drug is covered by their plan. The good news is that Keytruda infusions are covered by Medicare Part B as an outpatient prescription drug.
In this article, we’ll explore the parts of Medicare that cover Keytruda, as well as what your out-of-pocket costs might look like.
According to the Centers for Medicare & Medicaid Services (CMS), Medicare covers many of the prescription drugs that are necessary for cancer treatment.
Here is a quick breakdown of when different parts of Medicare will cover medications like Keytruda:
- Part A. Medicare Part A covers cancer drugs when they are given at the hospital during an inpatient stay.
- Part B. Medicare Part B covers cancer medications given as an infusion at an outpatient clinic or doctor’s office.
- Part D. Medicare Part D covers cancer drugs that are filled at a pharmacy and taken at home.
Keytruda is a prescription immunotherapy drug that is delivered via infusion every 3 weeks. This drug must be administered by a licensed medical professional, which means that it is considered an outpatient prescription drug.
Most Medicare beneficiaries also have some sort of prescription drug coverage. However, Medicare Part D usually only covers prescription drugs that are taken at home. This means that even if you have a Part D plan, Keytruda will likely not be covered under your prescription drug plan.
What about Part C (Medicare Advantage) coverage?
Medicare Part C (Medicare Advantage) is an insurance option offered by private insurance companies who have a contract with Medicare. Medicare Advantage plans offer the same coverage as original Medicare, while also offering additional benefits, such as prescription drug coverage, vision, dental, hearing care, and more.
If you are enrolled in a Medicare Advantage plan, Keytruda will be covered the same way as under original Medicare. However, the out-of-pocket cost of the drug may vary depending on the type of plan in which you’re enrolled.
To find out how much Keytruda will cost you out of pocket under your plan, contact your Medicare Advantage provider directly for a quote.
Can a Medigap plan help cover Keytruda?
Medigap is supplemental insurance for original Medicare that helps cover out-of-pocket expenses, such as deductibles, coinsurance, and copayments.
If you are enrolled in a Medigap plan, it doesn’t help cover any costs associated with Part D plans. However, since Keytruda is covered under Part B, you may owe less out of pocket with a Medigap plan.
Here’s how having a Medigap plan can help lower your out-of-pocket costs for Keytruda:
- Medigap plans C and F both cover your Part B deductible. However, these plans are no longer being sold to new beneficiaries as of January 1, 2020. If you already had either of these Medigap plans prior to 2020, you are allowed to keep it as long as it is offered.
- Medigap plans A, B, C, D, F, G, and M all cover Part B coinsurance costs. If you are enrolled in any of these Medigap plans, you’ll pay nothing out of pocket for Keytruda.
- Medigap plans K and L both cover only a portion of the Part B coinsurance. If you are enrolled in plan K, you will pay 50 percent of your coinsurance for Keytruda. If you are enrolled in plan L, you will only pay 25 percent of the coinsurance amount.
Keytruda is a brand-name prescription drug so it has a high out-of-pocket cost without insurance. According to the manufacturer, a single 200-mg intravenous dose of Keytruda costs $9,724.08 without insurance.
Since infusions are usually given every 3 weeks, the cost of this medication can easily add up without insurance.
Even with insurance coverage, such as Medicare, you may still end up paying for a portion of this drug out of pocket. Here’s a breakdown of what Keytruda generally costs for Medicare beneficiaries:
Costs with Part B
- You’ll pay the Part B deductible, which must be paid first before Medicare pays for covered services and medications. The deductible amount is $198 in 2020.
- Once the deductible has been met, you’ll pay 20 percent of the Medicare-approved amount for the service or prescription drug.
- Without supplemental insurance, about 80 percent of Medicare beneficiaries paid between $1,000 to $1,950 per infusion after meeting their Part B deductible.
Costs with Part C (Medicare Advantage)
- Roughly 41 percent of people with a Medicare Advantage plan paid nothing out-of-pocket for Keytruda.
- For Medicare Advantage plan beneficiaries who did have out-of-pocket costs, 80 percent of them paid between $0 to $925 per infusion after their plan’s deductible was met.
Ultimately, you’ll need to check your Medicare plan’s provider rules and prescription drug costs to determine your own out-of-pocket cost for Keytruda.
Additional help with costs
Merck, the manufacturer of Keytruda, offers an assistance program for certain qualifying individuals. To find out if you are eligible for this program, you can contact Merck by:
- calling 855-257-3932 (TTY 855-257-7332)
- visiting the Merck Access Program website
Cancer cells use certain pathways in the body, such as the programmed death receptor-1 (PD-1) pathway, to avoid detection by the immune system. By using these pathways to avoid detection, cancer can grow and spread.
Keytruda is a type of immunotherapy that blocks the PD-1 pathway. This allows the immune system to easily detect and fight these cancer cells.
What does Keytruda treat?
Keytruda has shown success in treating a variety of cancers, such as melanoma and non-small cell lung cancer. In one review from 2016, Keytruda was found to have an overall response rate of
Keytruda has been FDA-approved to treat:
- cervical cancer
- esophageal squamous cell carcinoma
- gastroesophageal junction adenocarcinoma
- head and neck squamous cell cancer
- hepatocellular carcinoma (liver cancer)
- Hodgkin’s lymphoma
- Merkel cell carcinoma
- non-small cell lung cancer
- primary mediastinal B-cell lymphoma
- renal cell carcinoma (kidney cancer)
What can I expect while taking Keytruda?
Keytruda infusions are administered roughly once every 3 weeks. It can be given alone or with other cancer treatments, such as chemotherapy and radiation.
During treatment with Keytruda, the most common side effects include:
- appetite loss
- shortness of breath
There are some rare but serious side effects associated with Keytruda treatment, including the development of an autoimmune condition where the body attacks itself. It’s always important to weigh the risks and benefits with your doctor to determine if treatment with Keytruda is right for you.
Are there other options besides Keytruda?
If you wish to discontinue treatment with Keytruda, your doctor may want to try another PD-1 inhibitor instead. Opdivo (nivolumab) is a similar cancer treatment drug that also works on the same pathway. There are other cancer treatment options as well, such as Tecentriq (atezolizumab) and Imfinzi (durvalumab), that work on PD-L1 pathways in a similar way.
Keytruda is a prescription immunotherapy drug that has shown promising success as a treatment for cancer. Medicare beneficiaries who need Keytruda infusions for their treatment are covered by Medicare Part B.
Before Medicare will pay for Keytruda infusions, the Part B deductible must be met, and then a 20-percent coinsurance amount will be paid out of pocket.
To find out how much Keytruda will cost under a Medicare Advantage plan, reach out to your plan provider or doctor for specific cost estimates.