What Medicare covers for Fotivda

Medicare Part B covers Fotivda (tivozanib) when prescribed by your doctor for advanced renal cell carcinoma (kidney cancer), but only under specific conditions. Your doctor must prescribe it, you must have the type of kidney cancer it treats, and you must be enrolled in Part B. The drug itself is covered as an injectable medication administered in a medical setting, not as a pill you pick up at a pharmacy.

Coverage is not automatic. Your doctor's office or the infusion center will need to verify your coverage before treatment begins. This verification step catches any gaps in your enrollment or reasons Medicare might deny the claim before you receive the drug.

Key Takeaways

  • Medicare Part B covers Fotivda for advanced renal cell carcinoma when your doctor prescribes it and administers it in a medical setting.
  • You pay a 20% coinsurance amount after you meet your Part B deductible, which varies by year.
  • Your doctor's office must verify coverage before your first infusion to confirm Medicare will pay its share.
  • If you have a Medigap or Medicare Advantage plan, your out-of-pocket costs may be lower than the standard 20% coinsurance.

How much you pay out of pocket

Under Original Medicare, you pay 20% of the approved amount for Fotivda after you meet your Part B deductible. The deductible amount changes each year. In 2024, the Part B deductible is $240, but confirm the current year's amount with Medicare or your provider.

The 20% coinsurance is calculated on Medicare's approved price for the drug, not the list price your doctor's office might quote. This approved price is usually lower than what an uninsured patient would pay. If you have a Medigap policy (supplemental insurance), it may cover some or all of that 20% coinsurance, depending on which Medigap plan you hold. If you have a Medicare Advantage plan instead of Original Medicare, your costs depend on your specific plan's formulary and cost-sharing rules.

What your doctor needs to do before treatment

Your oncologist's office will submit a prior authorization request to Medicare before your first dose. This is a standard step for cancer drugs. Medicare reviews whether the drug is appropriate for your diagnosis and whether you meet coverage rules. This process usually takes a few business days, though it can take longer if Medicare requests additional information from your doctor.

You should not schedule your infusion until your doctor confirms that prior authorization is approved. If you schedule early and authorization is denied, you may face unexpected bills or delays in starting treatment. Ask your doctor's office for a timeline — they can tell you when to expect approval and when to come in for your first infusion.

If Medicare denies coverage

If Medicare denies the prior authorization request, your doctor can appeal the decision. The appeal process has multiple levels, and your doctor's office typically handles the paperwork. They will submit additional clinical information explaining why Fotivda is medically necessary for your specific case.

While an appeal is pending, you have options. Some patients choose to pay out of pocket if they can afford it, though Fotivda is expensive. Others wait for the appeal decision. Ask your doctor about patient information programs run by the drug manufacturer — these programs sometimes cover costs for patients whose insurance denies coverage or who are uninsured. Your oncology social worker can also help you explore these programs.

Fotivda and other insurance you might have

If you have both Medicare and employer coverage (because you or a spouse still works), Medicare is usually the primary payer and your employer plan is secondary. Your employer plan may cover costs Medicare does not, but coordination rules explore. Contact your employer plan's benefits department to understand how they work together with Medicare.

If you have Medicaid in addition to Medicare (dual may be able to access), Medicaid may cover costs Medicare does not cover, such as the Part B deductible or coinsurance amounts. Rules vary by state. Your state Medicaid office or a benefits counselor can explain what Medicaid covers in your situation.

Questions to ask your doctor before starting Fotivda

Before your first infusion, ask your oncologist these questions to understand your coverage and what to expect:

  • Will you submit the prior authorization request to Medicare, and when should I expect approval?
  • What is the Medicare-approved price for each dose, and what will my 20% coinsurance be?
  • How often will I receive Fotivda infusions, and over how long a period?
  • If Medicare denies coverage, what is your plan to appeal?
  • Are there patient information programs I should know about if I have trouble paying my coinsurance?

When to contact Medicare directly

Contact Medicare (1-800-MEDICARE) if your doctor's office says Medicare denied coverage and you want to understand the reason yourself. You can also call if you receive a bill you believe Medicare should have paid. Have your claim number and dates of service ready when you call.

If you are having trouble affording your coinsurance, ask to speak with a Medicare counselor about your options. Some counselors can connect you with programs that help pay out-of-pocket costs for cancer patients. Your state's Health Insurance Counseling and Advocacy Program (HICAP) also offers free counseling about Medicare coverage questions.

Frequently Asked Questions

Does Medicare Part D cover Fotivda?

No. Part D covers oral medications you take at home, not injectable drugs given in a doctor's office or infusion center. Fotivda is covered under Part B as a medical service, not Part D as a pharmacy drug.

What if I have a Medicare Advantage plan instead of Original Medicare?

Medicare Advantage plans must cover Fotivda if your doctor prescribes it for kidney cancer, but your out-of-pocket costs depend on your specific plan. Call your plan's member services number to ask what you will pay for Fotivda infusions and whether prior authorization is required.

Can I get Fotivda at home instead of at an infusion center?

Fotivda is administered as an infusion in a medical setting such as a hospital or cancer center. Medicare does not cover it for home infusion. Ask your doctor or infusion center whether they offer flexible scheduling to make appointments easier for you.

What happens to my coverage if I switch from Original Medicare to a Medicare Advantage plan mid-year?

You can only switch Medicare Advantage plans during the annual enrollment period (October 15 to December 7) or if you may have access to for a special enrollment period. If you are in the middle of Fotivda treatment, switching plans mid-year is not usually possible. Talk to your doctor and a Medicare counselor before making any changes to your coverage.

Will Medicare cover Fotivda if my kidney cancer comes back after other treatments?

Yes, as long as your doctor prescribes it and you remain enrolled in Part B. Prior authorization will be required again. Your doctor will need to document that the cancer has returned and that Fotivda is medically appropriate for your current situation.