Medicare covers immunotherapy for certain cancers, but coverage depends on the type of immunotherapy, the cancer diagnosis, and whether you have Original Medicare or a Medicare Advantage plan

Immunotherapy is a cancer treatment that helps your immune system recognize and fight cancer cells. Medicare does cover some immunotherapy drugs and treatments, but not all of them, and not in every situation. The drugs that Medicare covers are those the Food and Drug Administration (FDA) has approved for specific cancers. Your coverage also depends on whether your doctor prescribes the treatment in a hospital, outpatient clinic, or as a take-home drug.

If you have Original Medicare (Part A and Part B), immunotherapy drugs given in a hospital or outpatient setting are covered under Part B. If the drug is a take-home injection or infusion, it may be covered under Part D (prescription drug coverage) if you have that plan, or under Part B if it is administered by a healthcare provider. Medicare Advantage plans (Part C) must cover at least what Original Medicare covers, but the details of copays, deductibles, and which drugs are on their formulary can vary by plan.

Key Takeaways

  • Medicare covers FDA-approved immunotherapy drugs for specific cancers when prescribed by your oncologist, but coverage is limited to approved uses.
  • Immunotherapy given in a hospital or outpatient clinic is covered under Medicare Part B, with you paying 20% of the Medicare-approved amount after you meet your Part B deductible.
  • Take-home immunotherapy drugs may be covered under Part D (if you have prescription drug coverage) or Part B depending on how the drug is delivered and administered.
  • Your Medicare Advantage plan must cover what Original Medicare covers, but your out-of-pocket costs, formulary restrictions, and prior authorization requirements may differ from Original Medicare.
  • Your doctor's office should verify coverage with Medicare or your plan before you start treatment, because coverage rules change and some drugs require prior authorization.

How Medicare Part B Covers Immunotherapy in Clinical Settings

When you receive immunotherapy as an infusion or injection in a hospital outpatient department or cancer clinic, Medicare Part B covers the drug itself and the administration. You pay 20% of the Medicare-approved amount for the drug and the infusion service after you meet your annual Part B deductible (which is $240 in 2024, though this amount can change each year). The provider bills Medicare directly, and Medicare pays its share to the provider.

The immunotherapy drug must be on Medicare's list of covered drugs for your specific cancer type and stage. Your oncologist will know which drugs are covered for your diagnosis. If your doctor wants to prescribe an immunotherapy drug that is not yet on Medicare's covered list, or for a use that Medicare has not approved, your doctor can request an exception, but Medicare may deny it. This is why it is important to have your doctor's office check coverage before your first appointment.

Prescription Drug Coverage Under Part D for Take-Home Immunotherapy

Some immunotherapy drugs come as take-home medications — pills, injections, or infusions you give yourself or a family member administers at home. These are usually covered under Medicare Part D (prescription drug coverage) if you have enrolled in a Part D plan. Part D coverage varies by plan: each plan has its own formulary (list of covered drugs), copay amounts, and deductible. A drug that is covered under one Part D plan may not be covered under another, or may have a higher copay.

Before you fill a take-home immunotherapy prescription, ask your pharmacy to check your Part D plan's formulary. If the drug is not on the formulary, your doctor can request a formulary exception, which the plan may grant if the drug is medically necessary and there is no suitable alternative on the formulary. This process can take a few days to a week, so start it as soon as your doctor prescribes the drug.

If you do not have Part D coverage, you can enroll during the annual enrollment period (October 15 to December 7 each year) or within 63 days of losing other drug coverage. If you miss the important date, you may have to wait until the next enrollment period, though some life events (like losing employer coverage) allow you to enroll outside the regular window.

Coverage Under Medicare Advantage Plans

Medicare Advantage plans (Part C) must cover all immunotherapy drugs that Original Medicare covers, but they can structure the coverage differently. Some Medicare Advantage plans may require prior authorization before you start immunotherapy, meaning your doctor must get approval from the plan before treatment begins. Others may place the drug on a higher cost tier, meaning you pay more out of pocket than you would under Original Medicare.

Check your Medicare Advantage plan's formulary and coverage rules before your first immunotherapy appointment. Call the plan's member services number (on the back of your card) and ask whether your specific immunotherapy drug is covered, what your copay will be, and whether prior authorization is required. If your plan denies coverage or charges a very high copay, you have the right to appeal the decision or to switch to Original Medicare during the annual enrollment period.

What Immunotherapy Drugs Medicare Covers

Medicare covers immunotherapy drugs that the FDA has approved for specific cancers. Common immunotherapy drugs that Medicare covers include checkpoint inhibitors like nivolumab (Opdivo), pembrolizumab (Keytruda), and atezolizumab (Tecentriq), as well as CAR-T cell therapies like tisagenlecleucel (Kymriah) and axicabtagene ciloleucel (Yescarta). However, Medicare's coverage is limited to the specific cancer types and stages for which each drug has been FDA-approved.

For example, Medicare may cover pembrolizumab for melanoma but not for a different cancer type, even if your doctor believes it could help. If your doctor wants to prescribe an immunotherapy drug for a use that is not yet FDA-approved (called off-label use), Medicare will not cover it unless your doctor submits a detailed request explaining why the drug is medically necessary for your situation. These requests are sometimes approved, but there is no may provide.

The list of covered immunotherapy drugs changes as new drugs are approved and as Medicare updates its coverage policies. Your oncologist's office will have the most current information about which drugs are covered for your specific diagnosis.

Out-of-Pocket Costs and Financial Help

Under Original Medicare Part B, you pay 20% of the Medicare-approved amount for immunotherapy drugs and infusion services after you meet your deductible. For expensive immunotherapy drugs, this 20% can add up quickly. If your costs are very high, you may reach your out-of-pocket maximum, after which Medicare covers 100% of your remaining Part B costs for the rest of the calendar year.

If you have a Part D plan and take a take-home immunotherapy drug, your copay depends on which tier the drug is on in your plan's formulary. Tier 1 drugs (generic) have the lowest copay; Tier 5 drugs (specialty) can cost hundreds of dollars per month. If your costs are high, you may reach the coverage gap (called the "donut hole"), where you pay a higher percentage of the drug cost. Once you spend enough out of pocket, you enter catastrophic coverage, where Medicare pays most of the cost.

If you cannot afford your immunotherapy costs, ask your oncologist's office about patient information programs run by the drug manufacturer. Many pharmaceutical companies offer free or reduced-cost drugs to people who meet income requirements. Your social worker or financial counselor at the cancer center can help you find and explore for these programs.

Prior Authorization and Getting Coverage Approved

Before you start immunotherapy, your doctor's office should contact Medicare (or your Medicare Advantage plan) to confirm that the drug is covered and to request prior authorization if it is required. Prior authorization means Medicare or your plan reviews your medical records and diagnosis to confirm that the immunotherapy is medically necessary before approving payment. This is not the same as your doctor's office checking whether the drug is on the formulary — it is a separate approval step.

Prior authorization can take anywhere from a few days to a few weeks. Your doctor's office should start this process as soon as your oncologist decides on your treatment plan. If Medicare or your plan denies prior authorization, your doctor can appeal the decision by submitting additional medical evidence. During the appeal, you can usually start treatment while waiting for a decision, though you may have to pay out of pocket initially.

Ask your doctor's office for a timeline: when will they submit the prior authorization request, when do they expect a decision, and what should you do if the request is denied? Having this information helps you plan your treatment schedule and budget.

Frequently Asked Questions

Does Medicare cover immunotherapy for all types of cancer?

No. Medicare covers immunotherapy drugs only for the specific cancer types and stages that the FDA has approved them for. Your doctor can request coverage for off-label use (a use not yet FDA-approved), but Medicare may deny it. Ask your oncologist which immunotherapy drugs are covered for your specific diagnosis.

What if my Medicare Advantage plan denies coverage for the immunotherapy my doctor recommended?

You have the right to appeal the denial. Your doctor can submit additional medical information to support the request. You can also switch to Original Medicare during the annual enrollment period (January 1 to March 31) if you want different coverage options. Contact your plan's member services for the appeal process.

Will I have to pay the full cost of immunotherapy upfront?

No. Medicare or your plan pays its share directly to the provider. You pay your copay or coinsurance at the time of service. If you cannot afford your share, ask about payment plans or patient information programs through the drug manufacturer or the cancer center's financial counselor.

Can I switch from my Medicare Advantage plan to Original Medicare if my plan does not cover my immunotherapy?

Yes, you can switch during the annual enrollment period (January 1 to March 31) or if you have a may have access to life event. If your plan denies coverage for a drug your doctor prescribed, that may may have access to as a reason to switch outside the regular enrollment window — ask your plan or call Medicare at 1-800-MEDICARE to confirm.

What happens if I start immunotherapy before Medicare approves prior authorization?

You may have to pay the full cost out of pocket until Medicare approves the authorization. Once approved, Medicare will reimburse you or the provider for the approved portion. To avoid this, have your doctor's office get prior authorization before your first treatment appointment whenever possible.