If you or a loved one has been diagnosed with lung cancer and your doctor has recommended Tagrisso as part of your treatment plan, you may be wondering if it is covered by Medicare. In this blog post, we will explore everything you need to know about the coverage of Tagrisso by Medicare.
What is Tagrisso?
Tagrisso, also known as osimertinib, is a targeted therapy medication used to treat non-small cell lung cancer (NSCLC) that has specific mutations in the epidermal growth factor receptor (EGFR) gene. It is designed to block the signals that promote the growth of cancer cells and is taken orally.
Is Tagrisso Covered by Medicare?
Yes, Tagrisso is covered by Medicare, but there are certain criteria that need to be met in order to qualify for coverage. Medicare Part B and Part D may provide coverage for Tagrisso, depending on the specific circumstances.
Medicare Part B Coverage
Medicare Part B covers medically necessary services and supplies, including some prescription drugs that are administered in a doctor's office or outpatient setting. In order for Tagrisso to be covered under Medicare Part B, it must be administered by a healthcare professional and meet certain criteria:
The patient must have a confirmed diagnosis of NSCLC with specific EGFR mutations
The patient must not have received previous treatment with Tagrisso
The patient's healthcare provider must determine that Tagrisso is medically necessary
If these criteria are met, Medicare Part B may cover a portion of the cost of Tagrisso.
Medicare Part D Coverage
Medicare Part D provides coverage for prescription drugs that are filled at a pharmacy. If Tagrisso is prescribed as a take-home medication, it may be covered under Medicare Part D. However, coverage may vary depending on the specific Part D plan.
It is important to note that Medicare Part D plans have formularies, which are lists of covered drugs. Each plan's formulary may differ, so it is essential to check with your specific Part D plan to determine if Tagrisso is covered and what the associated costs may be.
How to Determine Coverage
To determine if Tagrisso is covered by your Medicare plan, you can take the following steps:
Contact your Medicare Part D plan: Reach out to your Part D plan directly to inquire about coverage for Tagrisso. They can provide you with information on whether Tagrisso is on their formulary and what the associated costs may be.
Speak with your healthcare provider: Your healthcare provider can help determine if Tagrisso is medically necessary for your specific condition and guide you through the coverage process.
Review the Medicare website: The official Medicare website provides resources and information on coverage for specific medications. You can use their online tools to search for Tagrisso and see if it is covered by Medicare.
Other Considerations
While Tagrisso may be covered by Medicare, it is important to understand that there may still be out-of-pocket costs associated with the medication. These costs can include deductibles, copayments, and coinsurance.
Additionally, it is crucial to review your specific Medicare plan's coverage details, including any restrictions or limitations that may apply. Some plans may require prior authorization or step therapy before covering Tagrisso.
Conclusion
In conclusion, Tagrisso can be covered by Medicare, but it is essential to meet certain criteria and understand the coverage options available. If you or a loved one has been prescribed Tagrisso for the treatment of NSCLC, reach out to your Medicare Part D plan and healthcare provider to determine coverage and associated costs. Remember to review your plan's formulary and consider any out-of-pocket expenses that may apply. By understanding the coverage options, you can make informed decisions about your healthcare and access the necessary treatments for your condition.
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