Medicare does cover Arexvy, but only under specific conditions
Arexvy (glasdegib) is a cancer medication approved by the FDA for certain blood disorders. Medicare Part B covers Arexvy when it is administered in a hospital outpatient setting or through a Medicare-approved infusion center. However, coverage depends on your doctor's medical judgment that the drug is medically necessary for your condition, and you must meet the dosing and frequency requirements that Medicare recognizes.
If your doctor prescribes Arexvy in a hospital or outpatient clinic, the facility bills Medicare directly. You will owe your Part B coinsurance (typically 20% of the approved amount) after you meet your deductible. If Arexvy is prescribed as a take-home oral medication, coverage shifts to Part D (prescription drug coverage), which varies by plan.
Key Takeaways
- Medicare Part B covers Arexvy when given in a hospital outpatient department or infusion center, and you pay 20% coinsurance after your deductible.
- If Arexvy is prescribed as an oral medication to take at home, your Part D prescription drug plan determines coverage and cost-sharing.
- Your doctor must document that Arexvy is medically necessary for your specific diagnosis; Medicare will not cover it for off-label uses without prior authorization.
- Contact your Part D plan or Medicare directly at 1-800-MEDICARE before starting treatment to confirm your out-of-pocket costs.
How Medicare Part B covers Arexvy in hospital and clinic settings
When Arexvy is administered in a hospital outpatient department, an ambulatory surgery center, or a freestanding infusion clinic, Medicare Part B pays for the drug as an injectable medication. The facility submits a claim to Medicare, which pays 80% of the approved amount. You are responsible for 20% coinsurance, but only after you have met your Part B deductible for the year (which is $240 in 2024, though this amount changes annually).
The facility also bills separately for the administration of the drug — the nurse time, equipment, and monitoring. This administration fee is also covered under Part B with the same 20% coinsurance. If you receive Arexvy at a hospital outpatient department, you may also owe a facility charge. Ask the hospital's billing department for an estimate of your total out-of-pocket cost before your first infusion.
Some Medicare Advantage plans (Part C) cover Arexvy differently than Original Medicare. If you are enrolled in a Medicare Advantage plan, contact your plan directly to learn your specific copay or coinsurance amount, as it may differ from the 20% standard.
Part D coverage when Arexvy is prescribed as an oral medication
Arexvy is available as an oral tablet taken at home. If your doctor prescribes the oral form, your Part D prescription drug plan determines whether it is covered and what you pay. Part D plans vary widely — some include Arexvy on their formulary (the list of covered drugs), while others do not, or they may require prior authorization from your doctor before covering it.
To find out whether your Part D plan covers Arexvy, log into your plan's website, call the customer service number on your insurance card, or ask your pharmacist to check your coverage. You will need to know your plan name and member ID. If your plan does not cover Arexvy, your doctor can request a coverage exception, which the plan must review within 72 hours.
If Arexvy is covered, your out-of-pocket cost depends on which tier of your formulary it falls on. Most cancer drugs are placed on higher tiers, meaning you will pay more than you would for a generic medication. You may also hit the coverage gap (the "donut hole"), where you pay a larger share of the cost until you reach your out-of-pocket maximum.
Prior authorization and medical necessity documentation
Medicare requires that your doctor document why Arexvy is medically necessary for your condition. For most patients, this means your doctor must show that you have myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) and that Arexvy is appropriate for your stage and prior treatment history. Medicare will not cover Arexvy for other uses without a documented medical reason.
If you are receiving Arexvy through a hospital or infusion center, the facility's billing team usually handles prior authorization with Medicare. If you are taking the oral form through Part D, your pharmacy or doctor's office will submit the prior authorization request to your Part D plan. This process typically takes a few business days, though urgent requests can be reviewed faster.
If Medicare or your Part D plan denies coverage, you have the right to appeal. Your doctor can provide additional clinical information to support the appeal, and you can request an expedited review if the delay would harm your health.
What you pay out of pocket
Your actual cost for Arexvy depends on whether you receive it in a facility (Part B) or at home (Part D), your deductible status, and whether you have a Medigap or Medicare Advantage plan.
| Scenario | Your Cost |
|---|---|
| Hospital outpatient infusion, Original Medicare, deductible met | 20% of approved amount for drug + 20% of approved amount for administration |
| Hospital outpatient infusion, Original Medicare, deductible not met | Full deductible ($240 in 2024) + 20% coinsurance |
| Oral medication, Part D, formulary covered | Your plan's copay or coinsurance, which varies by tier and plan |
| Medicare Advantage plan | Your plan's copay or coinsurance; contact your plan for exact amount |
If you have a Medigap policy, it may cover some or all of your Part B coinsurance. Check your Medigap policy documents or call your Medigap insurer to confirm. If you have limited income, you may also be may be able to access for the Medicare Savings Program or Extra Help with Part D costs, which can reduce your out-of-pocket expenses significantly.
Steps to confirm coverage before you start Arexvy
Before your first dose, take these steps to avoid surprises. First, ask your doctor which form of Arexvy you will receive (infusion or oral) and in which setting. Second, if it is an infusion, contact the hospital or clinic's billing department and ask for an estimate of your out-of-pocket cost, including the facility fee if applicable. Third, if it is oral, contact your Part D plan and ask whether Arexvy is on your formulary and what your copay will be.
Fourth, call Medicare at 1-800-MEDICARE and confirm that your doctor's diagnosis and treatment plan are covered. You can also ask whether your deductible has been met for the year. Fifth, if you have a Medigap or Medicare Advantage plan, contact that plan directly to learn how they coordinate with Part B or Part D coverage. Sixth, ask your doctor's office whether they will submit prior authorization on your behalf, or whether you need to do it yourself.
Write down the names and phone numbers of everyone you speak with, along with the date and what they told you. If a claim is denied later, this record will help you appeal.
Frequently Asked Questions
Does Medicare cover Arexvy for all types of cancer?
No. Medicare covers Arexvy only for myelodysplastic syndrome and acute myeloid leukemia, the conditions for which it is FDA-approved. If your doctor prescribes it for another cancer type, Medicare will likely deny the claim unless your doctor documents a strong medical reason and requests a coverage exception.
What if my Part D plan does not cover Arexvy?
You can ask your doctor to request a coverage exception from your plan. The plan must review the request within 72 hours. If the plan denies the exception, you can appeal or ask your doctor whether a different medication on your plan's formulary might work for you. You can also switch to a different Part D plan during the annual enrollment period (October 15 to December 7).
Will I owe anything if I have a Medigap plan?
It depends on your Medigap plan. Some Medigap plans cover all of your Part B coinsurance, while others cover part of it. Check your Medigap policy or call your insurer to learn what your plan covers for cancer drugs and infusions.
Can I get Arexvy through a mail-order pharmacy instead of a clinic?
Arexvy is typically dispensed through a specialty pharmacy because it requires careful handling and monitoring. Ask your doctor or pharmacist whether a mail-order specialty pharmacy is an option for your situation. If so, your Part D plan will still explore, and your copay will be the same.
What happens if I cannot afford my share of the cost?
If you have limited income, you may be may be able to access for the Medicare Savings Program (which helps with Part B premiums and coinsurance) or Extra Help with Part D costs. Contact your state Medicaid office or call 1-800-MEDICARE to learn whether you may have access to. Your doctor's office or hospital social worker can also help you find financial information programs offered by the drug manufacturer.