Is Immunotherapy Covered By Medicare? Everything You Need To Know

Is Immunotherapy Covered By Medicare?

Which Medicare Parts Cover Immunotherapy?

Medicare’s coverage for immunotherapy involves different parts, each addressing specific aspects of the treatment.

Here’s a breakdown to guide you:

Medicare Part A

This part covers hospital stays for inpatient admissions and includes expenses related to:

• The stay itself
• Medications or therapies administered during the stay
• Meals
• Other associated costs

Also Read: Does Medicaid Cover Genetic Testing? Unraveling The Genetic Testing Options Under Medicaid

Medicare Part B

Part B covers visits to outpatient centers like doctor’s offices or standalone clinics.

When undergoing cancer treatments, Part B extends coverage to various therapies, including:

• Immunotherapy (specifically the CAR-T form)
• Chemotherapy
• Radiation treatments

Medicare Part C

Also known as Medicare Advantage, Part C is a private plan encompassing services covered under Parts A and B.

It may additionally include prescription drug coverage.

However, utilizing in-network providers and pharmacies is crucial for maximizing coverage under a Part C plan.

Also Read: Is Wellcare Medicaid or Medicare?: Demystifying Wellcare’s Healthcare Coverage and Eligibility

Medicare Part D

Part D covers prescription drugs taken outside healthcare facilities, such as at home.

The plan’s formulary and tier system determine the extent of coverage, categorizing medications based on cost.

Consult your plan provider to ascertain the coverage specifics before commencing treatment.

Medigap

Medicare supplement plans, or Medigap plans, fill in the gaps left by other Medicare coverage.

This includes deductibles for Parts A and B, along with copayments or coinsurance for Parts B and C.

Notably, Medigap plans don’t provide standalone prescription drug coverage or cover residual costs from Part D.

Is Immunotherapy Covered By Medicare? 

What is the cost of immunotherapy?

When embarking on your cancer treatment journey, the financial aspect may be a significant concern.

Medicare provides coverage for certain expenses related to immunotherapy.

Let’s delve into the specific costs when immunotherapy is included under each segment of Medicare.

Part A Costs

The deductible for Medicare Part A in 2021 stands at $1,484 per benefit period.

This is likely to be covered if you undergo all necessary visits and cancer treatment sessions.

Part B Costs

For 2021, the typical costs for Part B are as follows:

• Monthly premium: Usually $148.50, but it could be higher based on your income.
• Deductible: $203
• Copayment: 20 percent of the Medicare-approved cost for your immunotherapy treatments after meeting the deductible.

Part C Costs

Medicare Part C plan costs vary depending on the specific plan and provider.

Each plan comes with distinct copayment amounts, coinsurance, and deductibles.

Consult your plan provider for details about your coverage, costs, and any other inquiries about your plan.

Part D Costs

Costs and coverage for individual immunotherapy drugs under Medicare Part D can differ based on the medication. Using Keytruda as an example:

• Without insurance, a single dose of Keytruda costs $9,724.08. Typically, patients requiring Keytruda will need more than one dose.
• 80% of patients with traditional Medicare plans and no supplemental insurance paid between $1,000 and $1,950 per Keytruda infusion.
• 41% of patients with a Medicare Advantage plan had no out-of-pocket costs. For those with out-of-pocket expenses, the cost ranged between $0 and $925.

What is immunotherapy?

Immunotherapy represents a form of cancer treatment harnessing the body’s innate immune system to detect and eliminate cancer cells.

It encompasses four distinct types:

Monoclonal antibodies:

These can either be artificially created antibodies in a laboratory or a reinforcement of existing antibodies, working to combat cancer cells.

Oncolytic virus therapy

Utilizing genetically modified viruses, this immunotherapy targets and destroys cancer cells.

T-cell therapy

Primarily employed against blood cancers, this treatment involves deploying T-cells, a type of immune system cell, to locate and battle cancer cells.

Cancer vaccines

These aid the body in establishing a defense mechanism against cancer, serving as a preventive measure or a treatment approach.

Immunotherapy is often administered in conjunction with other cancer treatments such as chemotherapy or radiation, and it may follow surgery to ensure the eradication of any lingering cancer cells.

What to expect during immunotherapy treatment

Immunotherapy is prescribed for specific cancer types, including cervical cancer, esophageal cancer, hepatocellular carcinoma (liver cancer),;

Hodgkin’s lymphoma, non-small cell lung cancer, and renal cell carcinoma (kidney cancer).

What are the side effects of immunotherapy?

The side effects of immunotherapy can vary depending on the specific medication and its combination with other cancer treatments.

Common side effects may include dizziness, body aches, skin reactions, headaches, nausea, vomiting, and diarrhea.

These symptoms could also signal more severe medical conditions, necessitating immediate attention.

It is crucial to inform all medical providers about ongoing immunotherapy.

Conclusion

Different parts of Medicare cover the costs of immunotherapy.

To avail the coverage, you must meet the plan’s deductible and then pay specific coinsurance or copayment costs.

There are four distinct types of immunotherapy that can combat cancer independently or alongside other treatments.

Report any experienced side effects to your doctor promptly.

Medicare plan options and costs may undergo annual changes.