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Does Medicare Cover Pre Existing Cancer

Does Medicare Cover Xtandi?

Prostate cancer is a type of cancer that affects a lot of men. Most of the time, it affects men over the age of 60 rather than younger men. Traditional methods of treatment are often effective against prostate cancer, but not always.

The medication, Xtandi, is a different treatment used in treating advanced prostate cancer. This medication works by inhibiting androgen receptors.

If this is a treatment you are considering, one of the questions you likely have is, “does Medicare cover Xtandi?” In this article, we answer that question in clear, plain English. You will also find the average costs of Xtandi for those who have to pay for it out of pocket.

Does Medicare Cover Xtandi?

The short answer is no. In most cases, Medicare will not cover the cost of Xtandi. That said, there may be some situations where you can get these costs covered. Below we’ll take a closer look at this to see when you might be able to get Medicare to pay for your Xtandi. 

Original Medicare

Original Medicare (Medicare Part A and Part B) does not provide coverage for Xtandi. That is because Original Medicare mainly covers medically necessary services, equipment, and treatment rather than prescription drugs. Prescription drug coverage may be provided by either Medicare Advantage plans or by Medicare Part D.  

Part C and Part D Coverage for Xtandi

However, some Medicare Advantage plans (Medicare Part C) provide coverage for Xtandi. Medicare Advantage plans cover everything Original Medicare covers but will also cover things that Original Medicare does not. Exactly what these plans will cover and how much the treatment costs will depend on the specifics of your plan.

Medicare Part C plans that include prescription drug plans will also provide coverage for medications that your healthcare provider prescribes to you.

Medicare Part D plans also provide coverage for Xtandi. Part D is a prescription drug plan, and just like Medicare Part C, Medicare Part D plans are provided by private insurance companies. 100 percent of both Medicare Part C and Part D plans provide coverage for the medication Xtandi. 

Most Medicare plans restrict the amount of purchase for Xtandi per one time. If you need to purchase a greater amount of Xtandi at one time, Medicare may not cover it. You can either wait until the period has passed before refilling or  contact your plan provider and ask for an exception.

Xtandi is listed as a Tier 5 drug in the Medicare drug formulary. Most of the time, the Medicare drug formulary only has 5 tiers. Tier 5 medications are more expensive than Tier 1, 2, 3, and 4 medications.

Most Medicare plans also may require you to have prior authorization before they provide coverage for this medication. The usage of this medication has to be for medically necessary purposes. You must contact your plan provider to get authorization. 

How Much Does Xtandi Cost? 

The cost of a supply of 120 capsules of 40 mg Xtandi is around $12,800. This price varies depending on the pharmacy where you purchase it.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.

Additional Info on Medicare Coverage

This article is part of our series on “What does Medicare cover?”

Also, you can check out other articles in this series including: Does Medicare Cover Omnipod Dash?

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