Two 70-Year-Olds Face the Same $12,272 Keytruda Qlex Shots, but Medigap Plan G Leaves One Paying $0 After the Part B Deductible While the Other Pays 20% With No Spending Cap

Quick Read

• With Original Medicare only, a Keytruda Qlex patient pays 20% of Medicare’s approved amount for each injection, with no annual cap; Medigap Plan G removes that coinsurance after the deductible.

• The catch is access to Medigap: after open enrollment, insurers in most states can decline cancer patients or charge more, while Medicare Advantage limits in-network costs but can require prior authorization.

• Coinsurance is based on Medicare’s approved amount, not the $12,272 list price, so patients should ask for written estimates that separate the drug charge from administration fees before treatment starts.

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Two hypothetical 70-year-old cancer patients are preparing to begin the same therapy. Their oncologists have recommended Keytruda Qlex, a subcutaneous injection that takes about one minute to administer. The manufacturer lists each three-week dose at $12,272.

Both patients have Original Medicare. One also has Medigap Plan G, which pays his Part B coinsurance after the deductible. The other never enrolled in supplemental coverage. He would owe 20% of Medicare’s approved treatment cost every time, and there is no annual ceiling on what he could be charged.

The $12,272 List Price Is Not the Medicare Bill

Merck says the three-week dose carries a list price of $12,272 before discounts. Medicare, however, pays an approved amount for drugs administered by a doctor, and that payment is tied to the drug’s billing code. Qlex now has a permanent code. On Merck’s Q3 earnings call, oncology chief Jannie Oosthuizen said, “Since we received the permanent J-code on April 1, it has been a really positive trajectory.”

That means the patient’s 20% coinsurance is based on Medicare’s approved amount, not on the full list price. Calculating 20% of the list price would overstate what he owes. Keytruda Qlex was not included among the drugs chosen for Medicare price negotiations that will take effect in 2028.

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What Original Medicare Pays

Part B usually covers medically necessary cancer drugs given in a doctor’s office, clinic, or hospital outpatient department. After he meets the $283 Part B deductible for 2026, he would generally pay 20% of the Medicare-approved amount. Over a full year on a three-week schedule, that would mean about 17 injections. Each one creates its own 20% bill, and the office visits, scans, and lab work around the treatment can also trigger coinsurance.

Original Medicare does not include an annual out-of-pocket maximum. There is one limit for most hospital outpatient services: a single copayment generally cannot be more than the Part A inpatient deductible, which is $1,736 in 2026. That still does not cap his total yearly spending, so where the care is delivered matters.

The Same Treatment, Three Different Bills

Plan G covers his Part B coinsurance after the deductible. In practice, that means the injections, scans, and covered visits usually do not add more coinsurance, though he still pays the monthly premium. Medicare Advantage plans do place a cap on in-network costs, and that cap can be as high as $9,850 for 2027. But an Advantage plan may require approval before the first dose, restrict him to its network, and exclude Part D drugs and out-of-network care from the cap.

The bigger issue is what happens before coverage even starts. At age 70, his one-time Medigap open enrollment period ended years ago. In most states, insurers can now review his medical history, and a cancer diagnosis may lead to a denial or a higher premium. Switching from Advantage back to Original Medicare plus Plan G in the middle of treatment may not be possible. Connecticut, New York, Massachusetts, and Maine offer broader access, so it is important to check state rules. Coinsurance on a drug like Qlex is only one of Medicare’s surprises for retirees.

What the Faster Injection Changes

The IV version of Keytruda takes about 30 minutes. Qlex takes about one minute every three weeks, or about two minutes every six weeks. That can save time in the chair, parking costs, and long afternoons at an infusion center. Whether it saves money too depends on how Medicare pays both for the drug and for administering it, since that service has its own billing code. A shorter visit does not necessarily mean a smaller bill.

Three Steps to Take Before the First Dose

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