Keytruda (pembrolizumab) is an FDA-approved immunotherapy treatment for cancer. Medicare Part B covers it as an outpatient infusion to treat certain cancers.

Keytruda is a newer immunotherapy drug that has been FDA-approved to treat several types of cancer, such as melanoma and lung cancer.

With this new treatment option’s initial success, many Medicare beneficiaries may be wondering if their plan covers this drug. 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 and your out-of-pocket costs.

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:

  • Medicare Part A: This covers cancer drugs when they are given at the hospital during an inpatient stay.
  • Medicare Part B: This covers cancer medications given as an infusion at an outpatient clinic or doctor’s office.
  • Medicare Part D: This covers cancer drugs filled at a pharmacy and taken at home.

Keytruda is a prescription immunotherapy drug delivered via infusion every 3 to 6 weeks, depending on your specific treatment regimen. It must be administered by a licensed medical professional, which makes it an outpatient prescription drug.

Most Medicare beneficiaries also have some prescription drug coverage. However, Medicare Part D usually only covers prescription drugs that are taken at home. This means 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 that have a contract with Medicare. Medicare Advantage plans offer the same coverage as Original Medicare and additional benefits, such as prescription drug coverage, vision, dental, hearing care, and more.

If you’re 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 plan you’re enrolled in.

Contact your Medicare Advantage provider directly for a quote to determine how much Keytruda will cost you out of pocket under your plan.

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’re enrolled in a Medigap plan, it doesn’t help cover any costs associated with Part D plans. However, since Part B plans cover Keytruda, 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 sold to new beneficiaries as of January 1, 2020. If you already had either Medigap plan before 2020, you can keep them as long as they are offered.
  • Medigap plans A, B, C, D, F, G, and M all cover Part B coinsurance costs. If you’re enrolled in any of these Medigap plans, you’ll pay nothing out of pocket for Keytruda.
  • Medigap plans K and L cover only a portion of the Part B coinsurance. If you’re enrolled in Plan K, you will pay 50% of your coinsurance for Keytruda. If you’re enrolled in Plan L, you will only pay 25% of the coinsurance amount.

Keytruda is a brand-name prescription drug, so its out-of-pocket cost without insurance is high. According to the manufacturer, a single 200-milligram (mg) intravenous dose of Keytruda costs $11,337.36 without insurance.

Since doctors usually give infusions every 3 weeks, the cost of this medication can easily add up without insurance.

Even with insurance coverage, such as Medicare, you may still pay 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 is $240 in 2024. You must pay the deductible before Medicare pays for covered services and medications.
  • Once the deductible has been met, you’ll pay 20% of the Medicare-approved amount for the service or prescription drug.
  • According to the drug manufacturer’s data, about 80% of those insured by Original Medicare without supplemental coverage paid between $1,300 and $2,100 after fulfilling their Part B deductible.

Costs with Part C (Medicare Advantage)

  • According to the drug manufacturer’s data, 38% of Medicare Advantage plan members had no out-of-pocket costs for a 200-mg drug dose. Of those with costs, 80% paid between $0.01 and $925 after meeting their deductible.

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

Keytruda is a prescription immunotherapy drug that has shown promise as a cancer treatment. Medicare Part B covers Medicare beneficiaries who need Keytruda infusions for their treatment.

Before Medicare pays for Keytruda infusions, you must meet the Part B deductible, and then you will pay a 20% coinsurance amount out of pocket.

Contact your plan provider or doctor for specific cost estimates to determine the cost of Keytruda under a Medicare Advantage plan.