Medicare and Covering Clinical Trial Prescriptions

Got story updates? Submit your updates here. ›

A 65-year-old man fighting liver cancer and participating in a clinical trial for a $12,000-per-month cancer medication is concerned about his Medicare coverage when he enrolls in the program in two years. The article provides guidance on how Medicare's Part D prescription drug plans cover clinical trial medications, the end of the "donut hole" coverage gap, and strategies for enrolling in the right plan to minimize out-of-pocket costs.

Why it matters

As more patients participate in clinical trials for cutting-edge cancer treatments, understanding Medicare's coverage policies for these expensive medications is crucial. This story highlights the complexities patients face in transitioning from employer-sponsored health insurance to Medicare while managing the costs of life-saving clinical trial drugs.

The details

The man, Lee, is currently covered under his wife's employer health insurance and is paying $0 for a cancer medication through a clinical trial. However, he is concerned about what will happen when he enrolls in Medicare in two years, as the clinical trial medication costs over $12,000 per month. The article explains that Medicare Part D prescription drug plans may cover clinical trial medications if they are included in the plan's formulary, but patients may have to pay the plan's maximum out-of-pocket costs. It also notes that Medicare Advantage plans may cover some clinical trial costs in addition to the patient's plan coverage.

• Lee turns 65 in April.
• Lee's wife, Sarah, will retire and enroll in Medicare when she turns 65 in 2 years.

What they’re saying

What’s next

Lee will need to enroll in a Medicare Part D prescription drug plan that covers the expensive cancer medication he is receiving through the clinical trial when he and his wife, Sarah, transition to Medicare in two years.