Drug & Dose
Total Dose
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Billing Units
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Unit Size
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Self-Administered Drug (SAD) List
This drug appears on the CMS Self-Administered Drug Exclusion List. Drugs on this list are usually self-administered and may not be covered under Medicare Part B when self-administered. Commercial plans typically follow CMS guidance on the SAD list.
This information is provided as a courtesy. Coverage is determined on a case-by-case basis by the MAC processing the claim. You may still complete the cost estimate.
View CMS SAD List Article →
This drug appears on the CMS Self-Administered Drug Exclusion List. Drugs on this list are usually self-administered and may not be covered under Medicare Part B when self-administered. Commercial plans typically follow CMS guidance on the SAD list.
This information is provided as a courtesy. Coverage is determined on a case-by-case basis by the MAC processing the claim. You may still complete the cost estimate.
View CMS SAD List Article →
Primary Insurance
Manufacturer Assistance Programs Not Available
Most manufacturer-sponsored patient assistance programs (PAPs) disqualify applicants enrolled in Original Medicare or any Medicare Advantage / Medicare Replacement product. These programs are only available to patients with non-Medicare commercial insurance.
However, private foundation funding may be available for their diagnosis (e.g., HealthWell, PAN Foundation, Good Days).
Most manufacturer-sponsored patient assistance programs (PAPs) disqualify applicants enrolled in Original Medicare or any Medicare Advantage / Medicare Replacement product. These programs are only available to patients with non-Medicare commercial insurance.
However, private foundation funding may be available for their diagnosis (e.g., HealthWell, PAN Foundation, Good Days).
Patient Benefits & Pricing Step 2
Original Medicare Part B (2026)
Deductible: $283 · Coinsurance: 80/20 (Medicare pays 80%, patient pays 20%)
No Out-of-Pocket maximum. After the $283 deductible is met, the patient owes 20% of the Medicare-allowed amount with no cap.
Deductible: $283 · Coinsurance: 80/20 (Medicare pays 80%, patient pays 20%)
No Out-of-Pocket maximum. After the $283 deductible is met, the patient owes 20% of the Medicare-allowed amount with no cap.
Plan Details & Accumulations
Showing:
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$
$
$
Deductible remaining
$0.00
OOP remaining
$0.00
$
$
$
$
Family accumulations shown for reference. Individual accumulations above are used for this patient's cost estimate.
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Plan %Patient %
Pricing
Pricing: Medicare ASP + 6%
(CMS 2026 Q2)
Sec. deductible remaining
$0.00
Sec. OOP remaining
$0.00
Copay Assistance Auto-filled
Medicare patient: Manufacturer copay assistance programs are not available. Foundation programs may still apply.
Select a drug to see copay assistance details.
$
Cost Estimate
| CPT | Type | Item Name | Allowed/Unit | Qty | Total Allowed | Copay Override | Ded | Coins | No Assist | With Assist | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Totals | $0.00 | $0.00 | $0.00 | ||||||||
Patient Cost Estimate Summary Step 3
Without Copay Assistance
$0.00
with E&M (Office Visit)
$0.00
without E&M
With Copay Assistance
$0.00
with E&M (Office Visit)
$0.00
without E&M
Copy-Paste Template Output
CE Breakdown
Select a drug to generate the cost estimate template.
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