Does Medicare Cover Tagrisso?

As we age, our health becomes more and more of a priority. Many individuals rely on Medicare to cover their healthcare costs, but what happens when a specific medication is needed? In this case, we examine the question: does Medicare cover Tagrisso?

Tagrisso is a medication used to treat non-small cell lung cancer in patients with specific genetic mutations. It is a targeted therapy that can be life-saving for those with this type of cancer. However, the cost can be a significant concern for patients. So, let’s explore whether Medicare covers Tagrisso and what options are available for those who need it.

Does Medicare Cover Tagrisso?

Medicare is a federal health insurance program in the United States that covers a wide range of medical services and treatments. One of the questions that many people have is whether Medicare covers Tagrisso, a medication that is used to treat certain types of lung cancer. In this article, we will explore the coverage options for Tagrisso under Medicare.

What is Tagrisso?

Tagrisso (osimertinib) is a prescription medication that is used to treat non-small cell lung cancer (NSCLC) that has a specific genetic mutation known as EGFR. It works by blocking the activity of the mutated EGFR protein, which can slow or stop the growth of cancer cells. Tagrisso is typically taken orally, either as a tablet or a liquid, and is usually prescribed by an oncologist.

Tagrisso is a relatively new medication, having been approved by the Food and Drug Administration (FDA) in 2015. It is currently only approved for the treatment of NSCLC with the EGFR mutation, and is not used to treat other types of cancer.

Does Medicare Cover Tagrisso?

Medicare coverage for Tagrisso depends on several factors, including the type of Medicare plan you have, the stage of your lung cancer, and whether or not you have other health conditions. In general, Medicare will cover Tagrisso if it is deemed medically necessary by your doctor.

If you have Original Medicare (Part A and Part B), your coverage for Tagrisso will depend on where and how you receive your treatment. If you receive Tagrisso as an outpatient in a hospital or clinic, it will be covered under Medicare Part B. If you receive Tagrisso as part of your inpatient hospital stay, it will be covered under Medicare Part A. In either case, you will be responsible for paying your share of the costs, including deductibles, copayments, and coinsurance.

If you have a Medicare Advantage plan (Part C), your coverage for Tagrisso will depend on the specific plan you have. Medicare Advantage plans are offered by private insurance companies, and can vary in terms of the services and medications they cover. Some Medicare Advantage plans may cover Tagrisso, while others may not.

What Are the Costs of Tagrisso?

The cost of Tagrisso can vary depending on a number of factors, including your insurance coverage, the dosage and duration of your treatment, and the pharmacy you use. In general, Tagrisso is an expensive medication, with a monthly cost that can range from several thousand dollars to tens of thousands of dollars.

If you have Original Medicare, you will be responsible for paying your share of the costs for Tagrisso. This includes the Part B deductible, which is $203 in 2021, as well as a 20% coinsurance for the cost of the medication. If you have a Medicare Advantage plan, your out-of-pocket costs for Tagrisso will depend on the specific plan you have.

Are There Any Alternative Medications?

There are several other medications that are used to treat NSCLC with the EGFR mutation, including Tarceva (erlotinib), Iressa (gefitinib), and Gilotrif (afatinib). These medications work in a similar way to Tagrisso, by blocking the activity of the mutated EGFR protein. Your doctor can help determine which medication is right for you based on your specific health needs and medical history.

What Are the Benefits of Tagrisso?

Tagrisso has been shown to be effective in treating NSCLC with the EGFR mutation, with studies showing that it can slow or stop the growth of cancer cells. It may also help improve overall survival rates for patients with this type of lung cancer. In addition, Tagrisso is generally well-tolerated, with fewer side effects than some other cancer medications.

Tagrisso vs. Other Medications

Compared to other medications used to treat NSCLC with the EGFR mutation, Tagrisso has several advantages. It is a newer medication, which means that it may be more effective than older medications that have been on the market for longer. It may also have fewer side effects than other medications, which can improve quality of life for patients. However, Tagrisso is also more expensive than some other medications, which can be a barrier for some patients.

Conclusion

If you have NSCLC with the EGFR mutation and are considering treatment with Tagrisso, it is important to talk to your doctor about your Medicare coverage options. Medicare may cover Tagrisso if it is deemed medically necessary, but you will be responsible for paying your share of the costs. Your doctor can help you understand the benefits and risks of Tagrisso compared to other medications, and can work with you to develop a treatment plan that is right for you.

Frequently Asked Questions

Does Medicare Cover Tagrisso?

Yes, Medicare does cover Tagrisso. Tagrisso is an oral medication that is used to treat non-small cell lung cancer, and it is covered under Medicare Part B. To receive coverage for Tagrisso under Medicare, you must have a prescription from your doctor. Additionally, you must meet certain criteria to be eligible for Medicare coverage of Tagrisso.

The criteria for Medicare coverage of Tagrisso include having a diagnosis of non-small cell lung cancer, having tried and failed other treatments, and having a documented mutation in the EGFR gene. If you meet these criteria, your doctor can prescribe Tagrisso and Medicare will cover the cost of the medication.

What is the Cost of Tagrisso with Medicare?

The cost of Tagrisso with Medicare will depend on your specific plan and the dosage of the medication that you require. Generally, Medicare Part B covers 80% of the cost of Tagrisso and you will be responsible for the remaining 20%. However, if you have a Medicare Advantage plan, your out-of-pocket costs may be different.

It is important to note that there is a yearly deductible for Medicare Part B, which may impact the cost of Tagrisso. Additionally, if you have reached your yearly out-of-pocket maximum, you may not be responsible for any additional costs associated with Tagrisso. It is important to review your specific Medicare plan to understand your coverage and potential costs.

Can I Get Financial Assistance for Tagrisso with Medicare?

Yes, there are financial assistance programs available for individuals who require Tagrisso and have Medicare coverage. One program that may be available is the Extra Help program, which provides assistance with the costs of prescription drugs for individuals with limited income and resources.

In addition to the Extra Help program, there may be other financial assistance options available through Tagrisso’s manufacturer, AstraZeneca. These programs may include copay assistance or financial assistance for individuals who do not have insurance coverage.

What is the Process for Getting Tagrisso with Medicare?

The process for getting Tagrisso with Medicare will depend on your specific situation and the requirements of your Medicare plan. Generally, you will need to have a prescription from your doctor for Tagrisso, and you will need to meet the criteria for Medicare coverage of the medication.

Your doctor will likely need to submit documentation of your diagnosis and treatment history, as well as any test results indicating an EGFR mutation. Once Medicare has approved your coverage for Tagrisso, you can obtain the medication from a pharmacy that accepts Medicare coverage.

What are the Side Effects of Tagrisso?

Like all medications, Tagrisso can have side effects. Some common side effects of Tagrisso include diarrhea, rash, nausea, and fatigue. These side effects are generally mild to moderate in severity and can be managed with supportive care.

However, there are also more serious side effects associated with Tagrisso, including lung problems, heart problems, and eye problems. If you experience any of these side effects while taking Tagrisso, it is important to contact your doctor immediately to discuss your treatment options and potential risks.

In conclusion, while there is no straightforward answer to whether Medicare covers Tagrisso, the drug is covered under certain conditions. Patients with advanced non-small cell lung cancer who have not responded well to other treatments may be eligible for Medicare coverage of Tagrisso. However, it is important to note that coverage may vary based on individual circumstances and insurance plans.

If you or a loved one is considering Tagrisso as a treatment option, it is important to discuss coverage options with your healthcare provider and insurance company. They can help navigate the complex process of determining eligibility and coverage for this potentially life-saving medication.

Overall, while the cost of Tagrisso may be a concern for some patients, it is important to remember that access to proper medical treatment should never be compromised. With the right resources and support, patients with non-small cell lung cancer can receive the care they need to live their best lives.