Does Medicare Cover Keytruda?
Yes, Medicare covers Keytruda (pembrolizumab) for FDA-approved uses, such as certain cancers including melanoma, lung cancer, and head/neck cancers.[1] Coverage falls under Medicare Part B for drugs administered by a doctor in an outpatient setting, like infusions at a clinic. Medicare Part D plans may cover oral forms if available, but Keytruda is primarily IV.
What Are the Costs with Medicare Coverage?
After meeting the Part B deductible ($240 in 2024), you pay 20% coinsurance on approved amounts.[1] For Keytruda's average infusion cost around $10,000–$15,000 per dose, this means $2,000–$3,000 out-of-pocket per treatment before caps.[2] Annual out-of-pocket maximums apply via Medicare's design; high-cost patients hit a $2,000 cap in 2025 under the Inflation Reduction Act.[3]
| Scenario | Estimated Patient Cost per Dose (2024) |
|----------|---------------------------------------|
| Standard Part B (post-deductible) | 20% coinsurance (~$2,000–$3,000) |
| With Medigap (Supplement) Plan G | $0–$240 deductible only |
| With Extra Help (low-income) | $0–$4.90 copay |
Requirements for Medicare Approval
Keytruda requires prior authorization; Medicare only covers FDA-approved indications with supporting documentation like biopsy results or genetic testing (e.g., PD-L1 status).[1] Off-label use is rarely covered unless part of a clinical trial or compendia-supported.
How to Lower Costs if Medicare Coverage Falls Short
- Medigap policies: Plans F, G, or D cover the 20% coinsurance.[1]
- Manufacturer assistance: Merck's patient support program offers copay cards reducing costs to $0 for eligible commercially insured, but Medicare patients qualify for free drug via the Merck Patient Assistance Program if income is ≤500% federal poverty level (~$75,000 single).[4]
- Medicare Savings Programs: State aid for premiums/deductibles if low-income.
- Inflation Reduction Act caps: No more than $2,000 annual out-of-pocket for Part D drugs starting 2025; Keytruda shifts to Part D negotiation in 2028.[3]
Does Coverage Differ by Cancer Type or Stage?
Coverage aligns with FDA labels—yes for advanced non-small cell lung cancer, no for early-stage unless specified.[1] Check your doctor's NCD (National Coverage Determination) via Medicare.gov.
What If Your Claim Gets Denied?
Appeal with medical records showing FDA-approved use; 80%+ overturn on first-level review.[1] Use Medicare's coverage database or call 1-800-MEDICARE.
[1]: Medicare.gov - Keytruda Coverage
[2]: CMS Drug Pricing Files
[3]: Inflation Reduction Act Summary
[4]: Merck Access Program