Will Medicare pay for cost of Provenge? That’s a question many men ask, especially since most of the men eligible for Provenge are age 65 or older. The high cost of healthcare is a major hurdle for many individuals and families, and so when the Food and Drug Administration (FDA) approved the first and only immunotherapy for prostate cancer, Provenge (sipuleucel-T), excitement about the treatment turned to concern when the cost of treatment was revealed. At $93,000 for the three-treatment course of Provenge, plus other associated costs such as doctors’ visits, men with prostate cancer who are eligible for the treatment may be asking, will Medicare pay for cost of Provenge?
Who will pay for Provenge
On June 30, 2011, Medicare announced that it would pay for Provenge for prostate cancer treatment. This announcement was considered significant not only for obvious reasons, but also because private insurance companies tend to follow Medicare’s lead when it comes to covering drugs and procedures.
However, individual insurance carriers also make their own decisions about whether they will cover any specific treatment, and the high cost for Provenge could be a deterrent.
Regardless of whether Medicare or consenting private insurers are involved, only men who meet the current criteria for Provenge use will be considered for coverage. Those criteria are:
- Asymptomatic or minimally symptomatic prostate cancer, meaning men have no cancer pain or if there is pain, it does not require treatment with narcotics
- The cancer has spread (metastasized) beyond the tumor in the prostate to other organs and areas of the body, such as the bones or bladder
- The cancer has worsened despite treatment with hormone therapy, a situation also referred to as hormone resistant or hormone refractory prostate cancer
Men who are not eligible for Medicare therefore should contact their insurance carrier and discuss whether Provenge is on its list of approved treatments. If it is, they need to ask how much of the treatment will be covered and how much they will be required to pay out of pocket both for the treatment and associated costs.
To help with payment questions, the maker of Provenge, Dendreon Corporation, has established financial assistance programs. According to Dendreon, 75% of men receiving Provenge are expected to have minimal to no out-of-pocket costs. The three financial assistance programs include:
- Co-pay Assistance, which may help eligible men and their families with co-pays, co-insurance, and deductible costs
- Travel Cost Assistance, which may help with treatment-related travel costs for eligible patients
- Support for Patients without Coverage for Provenge, which may allow eligible patients to get Provenge free of cost through the PROVENGE Uninsured Patient Program
It’s important to note that both the Co-pay and travel assistance foundations offer help based on a patient’s financial need and according to criteria each individual foundation has established. These foundations are independent of Dendreon Corporation. While Dendreon can refer patients to these two assistance programs, it cannot guarantee that patients will meet the criteria set by the foundations nor that they will receive assistance as a result of the referral.
Similarly, patients who apply for the PROVENGE Uninsured Patient Program must meet certain criteria. Those criteria can be changed or the program can be discontinued at any time at the sole discretion of Dendreon Corporation. Individuals who are interested in learning more about what Dendreon has to offer can call Dendreon ON Call at 1-877-336-3736. Men who have questions concerning whether Medicare will pay for Provenge can contact Medicare directly.
Read more in our Prostate Cancer Health Center.