Medicare Coverage for Immunotherapy Cancer Treatment
Immunotherapy is covered under Medicare as a cancer treatment. Immunotherapy drugs such as Keytruda and Opdivo are typically covered under Medicare if the medications are deemed medically necessary. Expect to pay certain out-of-pocket costs for immunotherapy cancer treatment even if you are covered by Medicare.
Does Medicare Cover Cancer Immunotherapy?
Medicare covers certain types of immunotherapy to treat cancer. Immunotherapy uses medications made from living organisms to help your immune system fight cancer.
- Cancer vaccines
- Used for preventing cancer as well as treating it, these vaccines help your immune system recognize cancer cells and defend against the condition.
- Monoclonal antibodies
- These are synthetic, laboratory-produced antibodies that boost your own antibodies that would normally fight cancer cells.
- Oncolytic virus therapy
- This treatment uses a genetically-modified virus that can hunt down and destroy cancer cells.
- T-cell therapy
- This therapy relies on T-cells – a type of immune system cell – to find and destroy cancer cells. T-cell therapy is typically used to treat blood cancers.
Each part of Medicare — Part A hospital insurance, Part B medical insurance and Part D prescription drug plans — will cover different aspects of immunotherapy.
Medicare Advantage plans (Medicare Part C) are required by law to cover everything Medicare Part A and Part B cover but may include additional benefits depending on your particular plan.
- Medicare Part A hospital insurance
- Medicare Part A covers hospital stays related to immunotherapy treatments. You have to be admitted as a hospital inpatient before Part A coverage applies. Medicare Part A also covers costs for limited stays in skilled nursing facilities.
- Medicare Part B medical insurance
- Medicare Part B covers immunotherapy if you receive outpatient treatment in a doctor’s office or a freestanding clinic.
- Medicare Advantage (Medicare Part C) plans
- These plans are sold by private insurance companies and are required by law to cover everything Original Medicare — Medicare Part A and Part B — covers. These plans may also help pay for prescription drugs not covered by Original Medicare as well as other benefits. But you may be required to use doctors, hospitals and other health care providers that are in your plan’s network to avoid having to pay more out of pocket.
- Medicare Part D prescription drug plans
- Medicare Part D plans are sold by private insurers and can help you save money on drugs you are prescribed to take at home without the assistance of a health care professional. Your coverage amount depends on your plan and the plan’s formulary — a list of drugs your plan covers. Check with your plan administrator to get a better idea of the cost of medications used for your treatment.
- Medigap (Medicare Supplement insurance)
- Medigap helps cover the cost of deductibles, coinsurance and copayments you have to pay out of your own pocket when you are enrolled in Original Medicare. Medigap policies are sold by private companies. You cannot buy a Medigap policy if you are enrolled in a Medicare Advantage plan.
In addition to providing coverage for immunotherapy, Medicare covers radiation therapy and chemotherapy used to treat cancer.
Does Medicare Cover CAR-T Cell Immunotherapy?
The U.S. Centers for Medicare & Medicaid Services announced in 2019 that it would cover CAR-T cell (chimeric antigen receptor T cell) immunotherapy in certain cases.
This type of immunotherapy is highly personalized, using your own T cells to find and kill cancer cells. It’s also very expensive. As of 2019, a one-time treatment of CAR-T cell therapy was estimated to cost as much as $475,000, or up to $1.5 million if you include tests and hospitalization.
Medicare will only cover CAR-T cell therapy if you receive it in a hospital or other health care facility that is enrolled in the U.S. Food and Drug Administration’s Risk Evaluation and Mitigation Strategies (REMS) drug safety program.
The treatment also must meet other specific FDA requirements in order to be covered by Medicare Part B medical insurance.
Your Costs for Immunotherapy With Medicare
You will still have to pay certain out-of-pocket costs for immunotherapy cancer treatment even if you are covered by Medicare.
Your Medicare Part B deductible ($203 in 2021) applies. After meeting your deductible, you will also have to pay 20 percent of the Medicare-approved cost of your immunotherapy treatments.
Your Medicare Part A deductible ($1,484 in 2021 for each benefit period) will most likely be met if you complete all your necessary doctor visits and immunotherapy treatment sessions.
A Medigap policy may help cover some of your out-of-pocket costs if you have Original Medicare — Medicare Part A and Part B. Medigap plans are sold by private insurers. Check with your plan’s administrator to find out exactly what costs you may still be responsible for paying.
Medicare Advantage plans are also sold by private insurers. They are required by law to cover everything Original Medicare covers. Medicare Advantage plans also have a maximum out-of-pocket limit that may save you money.
Check with your Medicare Advantage plan administrator to find out the specific benefits your plan offers and to see if your plan provides additional benefits above what Original Medicare will cover.
Does Medicare Cover Keytruda or Opdivo for Cancer Treatment?
Medicare will typically cover Keytruda (pembrolizumab) or Opdivo (nivolumab) for cancer immunotherapy treatment if the medications are deemed medically necessary. Medicare may require that your doctor confirm the necessity of the treatment.
If your doctor prescribes a higher dose than the FDA recommends, Medicare may decline coverage of these treatments.
Both medications are expensive, and you will still be responsible for your Medicare Part B deductible plus 20 percent of the Medicare-approved costs for the drugs.
Your Costs for Keytruda
If you have Original Medicare and no Medigap coverage, your out-of-pocket costs after you reach your deductible could range from $1,000 to $1,950 for each Keytruda infusion, according to Merck & Co., the manufacturer of Keytruda.
A Medigap policy or Medicare Advantage plan may substantially reduce your out-of-pocket costs according to Merck. The company claims 41 percent of patients with Medicare Advantage plans had no out-of-pocket expenses for an infusion.
Since coverage for Medigap and Medicare Advantage plans vary depending on your plan and where you live, you should check with your plan administrator to determine exactly what your financial responsibility will be for Keytruda infusions.
Your Costs for Opdivo
Depending on the type and amount of Medicare coverage you have, you can expect to spend anywhere from zero dollars to as much as $2,670 per Opdivo infusion, according to Bristol-Myers Squibb Co., the manufacturer of Opdivo.
Bristol-Myers claims that more than 60 percent of patients paid $25 or less for each infusion in 2019.
Medigap and Medicare Advantage plans can greatly reduce your out-of-pocket costs. Check with your plan administrator about what your responsibility will be for your plan.
8 Cited Research Articles
- Nall, R. (2020, October 29). What to Know About Medicare and Keytruda. Retrieved from https://www.medicalnewstoday.com/articles/does-medicare-cover-keytruda
- Averett, N. (2019, December 23). Medicare to Cover CAR-T Cell Therapy. Retrieved from https://www.cancertodaymag.org/Pages/Winter2019-2020/Medicare-to-Cover-CAR-T-Cell-Therapy.aspx
- Bristol-Myers Squibb Company. (n.d.). Opdivo: Pricing Information. Retrieved from https://www.bmspricinginformation.com/opdivo
- U.S. Centers for Medicare & Medicaid Services. (2019, November). Medicare Coverage of Cancer Treatment Services. Retrieved from https://www.medicare.gov/Pubs/pdf/11931-Cancer-Treatment-Services.pdf
- National Cancer Institute. (2019, September 24). Immunotherapy to Treat Cancer. Retrieved from https://www.cancer.gov/about-cancer/treatment/types/immunotherapy
- U.S. Centers for Medicare & Medicaid Services. (2019, August 7). Decision Memo for Chimeric Antigen Receptor (CAR) T-Cell Therapy for Cancers (CAG-00451N). Retrieved from https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=291
- MedPAC. (2019, April 30). Payment Policy for Prescription Drugs Under Medicare Part B and Part D. Retrieved from http://www.medpac.gov/docs/default-source/congressional-testimony/04_30_2019_medpac_drug_testimony_for_eandc.pdf
- Merck Oncology. (n.d.). Keytruda: Cost Info & Financial Help. Retrieved from https://www.keytruda.com/financial-support/