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Medicare's Hidden Cancer Drug Cost Trap
8 Nov
Summary
- A hidden enrollment deadline affects Medicare coverage for cancer drugs.
- Original Medicare may leave patients with 20% coinsurance for Keytruda.
- Medigap Plan G covers Keytruda coinsurance after the deductible is met.
Two hypothetical 70-year-old men beginning the same one-minute cancer injection, Keytruda Qlex, will face vastly different Medicare bills. This divergence is due to a likely missed enrollment deadline years prior, impacting their supplemental insurance options. The manufacturer's list price for a dose is $12,272.
For those with only Original Medicare, after meeting the $283 Part B deductible for 2026, they will owe 20% of Medicare's approved amount for each injection, with no annual out-of-pocket limit. This can result in substantial costs over a year of treatment.
However, a patient with Medigap Plan G will have this coinsurance covered after meeting their deductible, significantly reducing their financial burden. Accessing Medigap after the initial open enrollment period is challenging, as insurers in most states can deny coverage or increase premiums based on health history, especially for cancer patients.
Medicare Advantage plans offer an out-of-pocket cap, potentially up to $9,850 for 2027, but may require prior authorization and limit care to in-network providers. Patients are advised to request written estimates detailing drug and administration fees and to confirm their Advantage plan's coverage rules before treatment begins.
