Does Medicare Cover Tarceva?

Knowing that you can afford your medication when you have lung or pancreatic cancer can be reassuring, so prescription drug coverage provides peace of mind. This guide explains whether Medicare Part D covers Tarceva and similar alternatives. 

What Is Tarceva?

Tarceva is a costly medication used to treat non-small cell lung cancer. It's a branded version of the generic drug erlotinib. Sometimes, doctors also prescribe Tarceva for people with advanced pancreatic cancer. Tarceva isn't suitable for many cancer types, so your doctor may perform tests to see if it's the right option for you.

Certain medications can interact with Tarceva, and smoking or consuming grapefruit products could increase the risk of experiencing adverse side effects. Side effects may include:

• Diarrhea
• Nausea
• Cough
• Shortness of breath
• Rash
• Reduced appetite
• Nail problems

Does Medicare Cover Tarceva?

Fortunately, 100% of Medicare Part D plans cover generic erlotinib or another drug with the same active ingredient, such as Tarceva. Original Medicare (Parts A and B) probably won't pay for Tarceva because it only covers medications administered directly by a health care provider, such as injectable drugs. 

Medicare Advantage plans are available through private insurers and must provide equivalent coverage to Original Medicare at a minimum. However, many Medicare Advantage policies offer enhanced benefits, which may include coverage for prescription drugs, such as Tarceva. 

Coverage for Tarceva varies between insurers, and you can find out whether you're covered by checking your policy's formulary. The formulary provides information about the drugs covered by a particular insurer. Tarceva and other erlotinib medications are expensive, so they usually fall under the highest tier (Tier 5). If your plan excludes Tarceva, your doctor may recommend generic erlotinib or another branded alternative.

How Much Is Tarceva With Medicare?

Tarceva costs around $1,665 for 30 150-milligram tablets. However, retail prices for Tarceva fluctuate between pharmacies and geographic areas, so you may pay slightly more or less for your medication.

You can sometimes find cheaper rates by comparing several pharmacies or subscribing to a medication discount service. You may need to visit a specialist pharmacy, as many won't stock Tarceva because of its high price point.

Medicare Part D and Medicare Advantage plans only start paying for prescription drugs after enrollees meet the annual deductible. Until then, you must cover the cost of your medication in full.

Medicare Part D insurers can't legally charge deductibles higher than $545, increasing from $505 in 2023. Therefore, you're likely to satisfy your deductible on your first prescription. Medicare Advantage deductibles are more variable, with some plans charging $0 deductibles and others charging into the thousands. 

After your coverage starts, you'll be responsible for contributing a co-pay toward the cost of your medication. Co-pays for Tarceva fluctuate significantly by provider, with most charging between $2 and $182.

Tarceva Medicare Restrictions

Most Medicare Part D insurers impose quantity restrictions and prior authorization requirements for Tarceva. Therefore, you'll need confirmation from your doctor that Tarceva is medically necessary and part of your treatment plan. Furthermore, your pharmacist can only give you a limited quantity of the drug per visit.