Immunotherapy Cost Guide: Insurance Coverage, Patient Assistance, and Financial Navigation

Immunotherapy drugs can cost $150,000-$500,000+ annually, but numerous programs help make treatment accessible. Understanding insurance coverage and assistance options is crucial for financial peace of mind.

**Actual Drug Costs (Without Insurance)**

Checkpoint Inhibitors (Annual Cost):
- Keytruda: $180,000-220,000
- OPDIVO: $180,000-250,000
- Tecentriq: $160,000-200,000
- Bavencio: $160,000-190,000

Antibody-Drug Conjugates:
- ADCETRIS: $200,000-280,000
- Enhertu: $180,000-240,000
- Kadcyla: $150,000-190,000

Targeted Therapies:
- Gleevec: $120,000-150,000 (generic cheaper)
- BRAF/MEK inhibitors: $180,000-240,000

Important: These are list prices. Actual costs vary significantly based on insurance, assistance programs, and negotiations.

**Insurance Coverage**

Medicare Coverage:

Part B (Infused Drugs):
- Covers IV immunotherapies (Keytruda, OPDIVO, etc.)
- 80% coverage after deductible
- You pay 20% coinsurance
- No out-of-pocket maximum
- Medigap can cover the 20%

Part D (Oral Drugs):
- Covers oral targeted therapies
- Varies by plan
- Subject to coverage gap ("donut hole")
- Out-of-pocket maximum $8,000 (2026)

Medicare Advantage:
- Often covers both infused and oral drugs
- Annual out-of-pocket maximum
- Varies widely by plan
- May have lower copays

Private Insurance Coverage:

Commercial Insurance:
- Usually covers FDA-approved immunotherapies
- Subject to plan deductible and coinsurance
- Annual out-of-pocket maximum ($9,000-18,000 typical)
- Higher premiums = lower out-of-pocket usually

Copay Tiers:
- Specialty tier (Tier 4-5) for cancer drugs
- 20-40% coinsurance common
- Can be $2,000-5,000+ per month
- Copay assistance programs crucial

Prior Authorization:
- Often required for expensive drugs
- Your oncologist's office handles this
- Approved if FDA-indicated
- Denial? Appeal immediately

**Manufacturer Copay Assistance Programs**

How They Work:
- Manufacturer pays your copay/coinsurance
- Up to annual limits ($25,000-50,000 common)
- Only for commercially insured patients
- Not available for Medicare/Medicaid (federal law)
- Significantly reduces out-of-pocket costs

Major Programs:

Merck Patient Assistance (Keytruda):
- Commercial insurance: $0 copay often
- Uninsured: Free drug if eligible
- Income limits for free drug
- Apply: 855-257-3932 or MerckAccessProgram.com

Bristol Myers Squibb (OPDIVO):
- Commercial insurance: Copay assistance available
- Uninsured/underinsured: Patient assistance
- Income-based eligibility
- Apply: 855-673-4861 or BMSAccessSupport.bmscustomerconnect.com

Seagen (ADCETRIS):
- SeaGen Patient Services
- Copay assistance for commercial insurance
- Free drug program for uninsured
- 855-473-2436

Daiichi Sankyo/AstraZeneca (Enhertu):
- Enhertu Co-Pay Program
- $0 copay for eligible patients
- Patient assistance for uninsured
- 833-368-4378

Novartis (Gleevec, other drugs):
- Novartis Patient Assistance Foundation
- Comprehensive support programs
- 800-277-2254

**Independent Charitable Assistance**

Patient Advocate Foundation:
- Copay assistance for eligible patients
- Disease-specific funds
- Income requirements
- Apply early - funds limited
- 866-512-3861 | PatientAdvocate.org

CancerCare Co-Payment Assistance:
- Financial assistance for treatment costs
- Limited funds, first-come basis
- Apply: 866-552-6729 | CancerCare.org

HealthWell Foundation:
- Covers copays for specific diagnoses
- Income limits (up to 500% federal poverty level)
- Apply when funds open
- 800-675-8416 | HealthWellFoundation.org

Leukemia & Lymphoma Society:
- Copay assistance for blood cancers
- Patient aid program
- 877-557-2672 | LLS.org

Pan Foundation:
- Disease-specific funds
- Covers medication copays
- Apply: 866-316-7263 | PanFoundation.org

**Financial Strategies**

Before Starting Treatment:

Meet with Financial Counselor:
- Every cancer center has one
- They know all assistance programs
- Apply to programs before starting treatment
- Maximize insurance benefits

Understand Your Insurance:
- What's your deductible?
- What's your out-of-pocket maximum?
- Which tier is your drug?
- Prior authorization process?

Timing Strategies:
- Start treatment early in calendar year
- Hit out-of-pocket max early
- Rest of year covered at 100%
- Plan multiple expensive treatments same year

During Treatment:

Stack Assistance Programs:
- Use manufacturer copay card
- Apply to charitable foundations
- Utilize hospital financial aid
- Combine multiple sources

Track All Expenses:
- Medical deductions on taxes
- Need receipts
- Mileage to appointments deductible
- Lodging for treatment deductible

For Medicare Patients:

Medicare Savings Programs:
- State programs to help with costs
- Qualified Medicare Beneficiary (QMB)
- Specified Low-Income Medicare Beneficiary (SLMB)
- Covers premiums and/or copays

Extra Help (Part D):
- Low Income Subsidy for drug costs
- Dramatically reduces Part D costs
- Apply through Social Security
- 800-772-1213

Medigap Policies:
- Supplemental insurance
- Covers the 20% Medicare doesn't pay
- Plan G most comprehensive
- Expensive but eliminates copays

**If Uninsured or Underinsured**

Manufacturer Patient Assistance Programs:
- FREE drug if income-eligible
- Income limits vary (150-400% federal poverty level)
- Applications require financial documentation
- Renewal annually

Hill-Burton Free Care:
- Some hospitals provide free/reduced care
- Facilities that received federal funds
- Income-based eligibility
- Ask hospital financial counseling

Clinical Trials:
- Drug provided free
- Monitoring covered
- May cover travel expenses
- NCI.gov/clinicaltrials to search

$340B Drug Pricing Program:
- Federally qualified health centers
- Safety-net providers
- Deeply discounted drugs
- Find providers: HRSA.gov

State Pharmaceutical Assistance Programs:
- Many states have programs
- Vary widely by state
- Income and age requirements
- Search: Medicare.gov/spap

**Negotiating and Appeals**

If Treatment Denied:

Appeal Immediately:
- Insurance denials often overturned
- Your oncologist provides medical justification
- Cite clinical trial data
- Emphasize FDA approval

External Review:
- If internal appeal fails
- Independent reviewer decides
- Often successful for cancer drugs
- No cost to you

Hospital Financial Aid:
- Nonprofit hospitals required to provide charity care
- Income-based sliding scale
- Can cover large portions of bills
- Apply even if partially insured

Medical Bills:

Negotiate Bills:
- Hospital bills often negotiable
- Ask for itemized bill
- Dispute errors
- Request payment plan

Never Ignore Bills:
- Communicate with providers
- Explain financial hardship
- Set up payment plans
- Avoid collections if possible

**Tax Deductions**

Medical Expense Deductions:
- Deduct expenses >7.5% of AGI
- Includes drugs, travel, lodging
- Keep meticulous records
- Can be substantial for cancer patients

Health Savings Account (HSA):
- Tax-free for medical expenses
- Fund if you have high-deductible plan
- Can pay cancer costs tax-free

**Questions to Ask**

Insurance:
- What will my out-of-pocket cost be?
- Is prior authorization needed?
- What's my plan's out-of-pocket maximum?
- Do I need specialty pharmacy?

Financial Counselor:
- What assistance programs am I eligible for?
- Can you help me apply?
- What will I actually pay per treatment?
- What if I can't afford it?

**Bottom Line**

Few patients pay full price for immunotherapy:
- Insurance covers most
- Copay assistance reduces out-of-pocket
- Patient assistance provides free drugs if uninsured
- Financial counselors navigate the system

DO NOT skip cancer treatment due to cost concerns. Help is available.

If you're told treatment is unaffordable, seek a second opinion from a financial counselor at a comprehensive cancer center. They have expertise in maximizing assistance.

Our team can connect you with financial navigation resources and assist with access programs.