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Keytruda Covered by Insurance: A Comprehensive Guide

What is Keytruda?

Keytruda, also known as pembrolizumab, is a medication used to treat various types of cancer, including melanoma, lung cancer, and head and neck cancer. It is a type of immunotherapy that works by boosting the body's natural defense system to fight cancer cells.

Is Keytruda Covered by Insurance?

The answer to this question is not a simple yes or no. Keytruda is a prescription medication, and its coverage by insurance plans varies depending on several factors. In this article, we will explore the current landscape of Keytruda coverage by insurance plans and provide guidance on how to navigate the process.

Keytruda Coverage by Insurance Plans

Medicare Coverage

Medicare Part B covers Keytruda for certain types of cancer, including melanoma, lung cancer, and head and neck cancer. However, patients may need to pay a copayment or coinsurance for each infusion.

Medicaid Coverage

Medicaid coverage for Keytruda varies by state. Some states cover Keytruda for certain types of cancer, while others may not. Patients should check with their state Medicaid program to determine coverage.

Private Insurance Coverage

Private insurance plans, including employer-sponsored plans and individual plans, may cover Keytruda for certain types of cancer. However, coverage and copays vary widely depending on the plan. Some plans may require a prior authorization or step therapy before covering Keytruda.

Cost of Keytruda

The cost of Keytruda can be significant, with a single infusion costing around $12,000. The total cost of treatment can range from $100,000 to $200,000 or more, depending on the type of cancer and the number of infusions required.

How to Get Keytruda Covered by Insurance

Step 1: Check Your Insurance Plan

Patients should first check their insurance plan to see if Keytruda is covered. They should review their plan documents or contact their insurance provider to determine coverage.

Step 2: Get a Prescription

Patients must get a prescription from their doctor to obtain Keytruda. Their doctor will need to determine if Keytruda is appropriate for their condition and will need to submit a prior authorization request to the insurance plan.

Step 3: Submit a Prior Authorization Request

The doctor's office will need to submit a prior authorization request to the insurance plan, which may include providing medical records and test results. The insurance plan will review the request and make a decision on coverage.

Step 4: Appeal a Denial

If the insurance plan denies coverage, patients can appeal the decision. They should contact their insurance provider to understand the appeals process and gather necessary documentation.

Key Takeaways

* Keytruda is a prescription medication used to treat various types of cancer.
* Insurance coverage for Keytruda varies depending on the type of insurance plan and the patient's condition.
* Patients should check their insurance plan to see if Keytruda is covered and should get a prescription from their doctor.
* Patients should submit a prior authorization request to the insurance plan and appeal a denial if necessary.

FAQs

Q: Is Keytruda covered by Medicare?

A: Yes, Medicare Part B covers Keytruda for certain types of cancer.

Q: Is Keytruda covered by Medicaid?

A: Coverage varies by state. Patients should check with their state Medicaid program to determine coverage.

Q: How much does Keytruda cost?

A: The cost of Keytruda can range from $100,000 to $200,000 or more, depending on the type of cancer and the number of infusions required.

Q: How do I get Keytruda covered by insurance?

A: Patients should check their insurance plan, get a prescription from their doctor, submit a prior authorization request, and appeal a denial if necessary.

Q: What if my insurance plan denies coverage?

A: Patients can appeal a denial by contacting their insurance provider and gathering necessary documentation.

Sources

1. DrugPatentWatch.com. (2022). Pembrolizumab (Keytruda) Patent Expiration. Retrieved from <https://www.drugpatentwatch.com/patent/US-9315541>
2. Centers for Medicare and Medicaid Services. (2022). Medicare Coverage of Immunotherapy. Retrieved from <https://www.cms.gov/newsroom/medicare-coverage- immunotherapy>
3. National Cancer Institute. (2022). Pembrolizumab (Keytruda). Retrieved from <https://www.cancer.gov/about-cancer/treatment/types/immunotherapy/pembrolizumab>
4. American Cancer Society. (2022). Pembrolizumab (Keytruda). Retrieved from <https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/immunotherapy/pembrolizumab.html>

Highlight

"Pembrolizumab (Keytruda) is a 'breakthrough therapy' that has shown significant promise in treating various types of cancer." - Dr. David F. McDermott, Director of the Melanoma Program at Massachusetts General Hospital (Source: National Cancer Institute)