Does Medicare Cover Immunotherapy for Cancer Treatment?
Key takeaways:
Medicare covers medically necessary cancer treatment, including immunotherapy.
Which part of Medicare pays for the treatment depends on how you receive the drugs.
Out-of-pocket costs for immunotherapy include copays, coinsurance, and deductibles.
Immunotherapy is a cancer treatment that helps your body's immune system fight cancer cells. Breast, kidney, and lung cancer are among the types of cancer that can be treated with immunotherapy. Oncologists typically combine immunotherapy with other cancer treatments such as chemotherapy, surgery, or radiation therapy.
If you have Medicare, many of the costs associated with immunotherapy may be covered under your insurance plan. Different parts of Medicare cover your treatment based on whether it’s inpatient, outpatient, or self-administered.
How much does immunotherapy for cancer treatment cost?
The cost of this cancer treatment depends on many factors, such as:
The type and stage of cancer being treated
The type of immunotherapy
How often you get immunotherapy
The cost per dose
Whether the treatment has market competition
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Oncologists use several types of immunotherapies to treat cancer, including immune checkpoint inhibitors, T-cell transfer therapy, and monoclonal antibodies. Prices can range from $1,000 to more than $400,000.
For example, the list price for a single infusion of the immunotherapy medication Opdivo at 3 mg/kg is $7,053. If your healthcare provider combines Opdivo with a 1mg/1kg infusion of Yervoy, the list price would be $23,134. These prices exclude biomarker testing, administration, and infusion center costs. Typically, you won’t have to pay the list price if you have insurance or a copay savings card.
The table below shows different types of immunotherapies your doctor may recommend.
| Type of Immunotherapy | Purpose | Examples |
|---|---|---|
| Immune checkpoint inhibitors | Stops specific checks and balances that your body usually uses to keep your immune system from overacting> |
|
| T-cell transfer therapy | Enables your immune cells to fight cancer better |
|
| Monoclonal antibodies | Helps your immune system locate cancer cells so that your body can destroy them |
|
| Immune system modulators | Improves your immune system’s response to cancer |
|
| Treatment vaccines | Assists your immune system in identifying, finding, and eliminating cancer cells |
|
Does Medicare cover immunotherapy?
Yes, Medicare provides coverage for immunotherapy. It falls under medically necessary cancer treatment supplies, services, and prescription drugs. The way your immunotherapy is administered determines which part of Medicare — Part A (hospital), B (medical), or D (prescription drugs) — will cover the treatment.
Part A covers inpatient immunotherapy during a hospital stay.
Part B covers outpatient immunotherapy in a doctor’s office or clinic.
Part D covers self-administered immunotherapy at home.
Medicare Advantage plans, also called Part C, are private plans. They usually cover everything covered by Parts A, B, and D. Part C plans must offer the same coverage as original Medicare, but they may have different costs and requirements.
How do the different parts of Medicare cover immunotherapy?
Medicare saves you money on the expenses associated with immunotherapy. Each part of Medicare covers immunotherapy, but their coverage differs according to how you receive the treatment.
For example, Part B covers the drugs in the above table (except for immune system modulators, which are self-administered) when administered in an outpatient setting. However, you may have to pay up to 20% of the cost, depending on your Medicare benefits. If you have a supplemental insurance plan, it can help pay for some or all of the out-of-pocket costs that are not covered by Part B.
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Self-administered drugs such as immune system modulators fall under Part D. All drugs must meet certain criteria to be covered. For example, there are four requirements for Tecartus to be used to treat mantle cell lymphoma (MCL). To ensure that Medicare covers a specific treatment and to get an idea of how much it might cost, check to see if the drug is on your plan’s formulary (or list of covered drugs) and check the drug’s tier. A drug in a lower tier generally costs less than a drug in a higher tier.
What are the out-of-pocket costs you should consider?
While Medicare covers most immunotherapy costs, you may have out-of-pocket expenses such as deductibles, coinsurance, and copayments. Your total costs for immunotherapy may depend on the type of treatment you receive, the stage of cancer being treated, and your overall health.
Here’s the breakdown for 2023 Medicare costs:
Medicare Part A: If you’re hospitalized, you’ll pay a $1,600 deductible for each benefit period (covered episode) under Part A. In a calendar year, this deductible may have to be paid more than once. Coinsurance does not begin until after 60 days of hospitalization. If necessary, Part A also covers limited stays at skilled nursing facilities.
Medicare Part B: The deductible for all Medicare beneficiaries in 2023 is $226, down from $233 in 2022. Under Part B, you’ll generally pay 20% of the Medicare-approved charge for most doctor services, outpatient therapy, and durable medical equipment after you pay the deductible.
Medicare Part D: Outpatient drugs from a pharmacy are covered by your prescription drug plan through Part D. Your plan's coverage, the pharmacy you select, and your Medicare drug coverage phase determine how much you pay.
Medigap: If you have original Medicare, Medicare supplement insurance, also known as Medigap, helps cover out-of-pocket costs from Parts A and B. There’s no out-of-pocket limit for traditional Medicare.
For most beneficiaries, the standard Part B monthly premium is $164.90 in 2023. You may pay more for Part B if you have higher income.
Premiums for Medicare Advantage (Part C) and Part D vary by plan. Medicare Advantage (MA) typically has set copays instead of a coinsurance percentage, which may help you better estimate expenses. MA plans have an out-of-pocket maximum, which is a limit on how much you can spend in a year.
Medigap insurance can help people with original Medicare pay for Part A and Part B deductibles, copays, and coinsurance. It’s sold by private insurers that have contracts with Medicare. There are 10 standardized national Medigap plans. The Medicare website explains what they cover and offers a comparison.
What is the process of getting immunotherapy covered by Medicare?
First, determine whether your immunotherapy provider and facility accept Medicare. If they do, check your plan for preauthorization requirements. Parts A and B don’t need preauthorization, but Parts C and D may require it.
Part B will also help pay for a second or third opinion on whether you should receive immunotherapy. After meeting your deductible, you’ll pay 20% of the Medicare-approved amount, and Medicare pays 80%. This breakdown may be different if you have a Medicare Advantage plan.
Can Medicare supplement insurance help cover immunotherapy?
Medigap policies can pay 50% to 100% of your out-of-pocket costs. The percentage depends on your plan.
For example, Medigap Plan A pays 100% of your Part A coinsurance and hospital costs for up to 365 days after your Medicare benefits are used. It also pays 100% of your Part B coinsurance or copayment. Plan C also covers 100% of these benefits and 100% of your Part A and Part B deductibles. Look up your Medigap plan to view your benefits.
What other resources can help pay for immunotherapy?
Some pharmaceutical companies have programs to help pay for immunotherapy prescriptions if you have Part D coverage. Use this online tool to see if there’s a pharmaceutical assistance program for your cancer treatment.
Patient assistance programs (PAPs) managed by nonprofits and government agencies may also provide a discount. They may even cover the full cost of immunotherapy treatments.
Examples of PAPs include:
In addition, you may be able to get access to immunotherapy by participating in cancer clinical trials. First, find a clinical trial that matches your diagnosis, stage, and treatment history. Then schedule an appointment to discuss your results.
Bottom line
Medicare offers coverage for immunotherapy. Which part of Medicare provides coverage depends on how you get the treatment. Check your plan or speak with a Medicare representative to get specific information about your coverage.
Also, expect to pay out-of-pocket expenses, such as copays, coinsurance, and deductibles. Medigap policies, pharmaceutical assistance programs, and clinical trials can offset these costs.
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References
Bristol Myers Squibb. (2022). Opdivo pricing information.
Centers for Medicare and Medicaid Services. (2011). Medicare benefit policy manual.
Medicare.gov. (n.d.). How to compare Medigap policies.
Medicare.gov. (2021). Getting a second opinion before surgery.
Medicare.gov. (2022). Medicare coverage of cancer treatment services.
U. S. Department of Health and Human Services. (2023). Medicare parts A and B coverage and prior authorization.
