Does Medicare Cover Keytruda? 

In the fight against cancer, all kinds of new technologies are making their way to the forefront. Although traditional therapies like radiation and chemotherapy are still useful as cancer treatments, newer technologies using stem cells and humanized antibodies are providing additional options for people suffering from lung cancer and other hard-to-treat cancers.

Humanized antibodies are antibodies that have come from non-human sources. These antibodies undergo a technical process during which protein sequences are modified to allow the antibodies to be used in humans. One of the most notable medications using this type of technology is Keytruda (pembrolizumab), an injectable medication that is infused with a person’s blood to make cancer cells vulnerable to attack.

How does Keytruda work?

Keytruda blocks a specific pathway in lymphocytes that cancer cells use to obfuscate their location. Because cancer cells have nowhere to hide after this pathway has been blocked, the natural immune system can find and attack the cancerous cells. In addition to receiving infusions of Keytruda, you may also receive chemotherapy as an adjunct therapy to aid in cancer elimination.

Does Medicare cover Keytruda?

Cancer can strike at any age, but older Americans tend to face an increased risk of cancer. As a result, seniors may be curious to know whether Medicare benefits cover Keytruda, and if they do, what is the cost to Medicare recipients?

Thankfully, most Medicare coverage plans provide benefits for Keytruda, but how Keytruda is covered will depend on how and where it is administered. Because Keytruda is an infused medication that requires administration by a trained medical professional, it is not taken at home like most prescriptions. Instead, it is administered either at a hospital during inpatient treatment or in a clinical setting as an outpatient treatment. 

Medicare Part B and Keytruda coverage

When administered as outpatient treatment in a clinical setting, Medicare benefits cover Keytruda through Medicare Part B. This part of Medicare covers various types of outpatient treatment as well as doctor visits, lab work, and durable medical equipment.

You will likely also require lab tests and diagnostics to be performed if you’re receiving Keytruda infusions. Medicare recipients who receive Keytruda need to be monitored for the possibility of adverse reactions. Original Medicare usually covers these under Part B as well.

Once you have met your deductible for the benefit period, Original Medicare benefits pay for 80% of your outpatient costs while you cover the remaining 20%. Medicare Part B also requires a monthly premium that must be current in order for benefits to continue.

Medicare Part A and Keytruda coverage

If you are receiving Keytruda infusions as part of inpatient care while admitted to a hospital or skilled nursing facility, Medicare Part A would apply toward coverage instead. Medicare Part A is the inpatient benefit of Original Medicare, and it provides up to 60 days of 100% coverage per benefit period for inpatient admission and associated treatment. Beyond 60 days, you can utilize an additional 30 days of inpatient coverage at a discounted rate. After 90 days, inpatient benefits can continue if you use lifetime reserve days. If no lifetime reserve days are available to use, Medicare recipients pay the total cost of care for continued inpatient treatment until the next benefit period begins.

Medicare Part D and Keytruda coverage

Some Medicare recipients carry prescription drug coverage through Medicare Part D. This optional coverage is used to pay for prescription medications that can be purchased from retail pharmacies for self-administration. Because Keytruda is administered as an infusion by a medical professional in a clinical setting, Medicare benefits under Part D do not apply toward the cost of Keytruda.

Medicare Part D may, however, pay for other medications that are prescribed for use in conjunction with Keytruda. These medications may pertain to your cancer or they may be prescribed to alleviate some of the symptoms that can come along with cancer treatment. In order to know whether a prescription is covered by your plan, you will want to consult your plan’s formulary. 

How does Medicare Advantage (MA) cover Keytruda?

Medicare Advantage plans are required to include at least the same coverage as Original Medicare Part A and Part B. Keytruda would be included in your MA plan’s coverage, but your plan may also include additional benefits at little to no extra cost. Check with your plan directly for specific coverage information.