CareCost Medicare allows
$60.645
per unit · ASP+6%, Q3 2026
Original Medicare: the patient owes $2,452.45 for a 200 mg infusion
Medicare allows $12,262.27 for the drug and its administration. The patient owes 20% of it once the Part B deductible is met, and a Medigap plan can take that to $0.
Estimate for your patient ↓Pick the dose and schedule, choose the plan, and add a Medigap plan if there is one.
200 mg every 3 weeks and 400 mg every 6 weeks deliver the same annual drug volume · pediatric dosing is weight-based
30-minute infusion: 96415 (each additional hour) does not apply.
Include only when a significant, separately identifiable E/M service is performed and documented (modifier 25).
| Item | Qty | Payer allows | Patient owes |
|---|---|---|---|
| Keytruda (pembrolizumab) J9271 | 200 | $12,129.00 | $2,425.80 |
| Infusion administration, initial hour 96413 | 1 | $133.27 | $26.65 |
| Total | $12,262.27 | $2,452.45 |
Medicare's 80% payment is reduced by the 2% sequester; the patient's 20% coinsurance is not affected.
The estimate above assumes the deductible is already met. Most patients are part-way through theirs for most of the year, and that changes what they owe today.
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Original Medicare · Keytruda · 200 mg
Patient owes · deductible met
Commercial estimates use the payer’s published rate and this patient’s actual benefits.
$60.645 per mg is Part B's ASP+6% rate for Q3 2026. A single dose exceeds $12,000, so the 20% coinsurance is far larger than a typical infused-drug copay — $2,425.80 on the drug alone for a 200 mg dose every three weeks, once the $283 Part B deductible is met, with no annual out-of-pocket maximum to cap it. Full explanation: How Medicare Part B drug cost sharing works →
Medicare pays J9271 per 1 mg billing unit, not per vial or per dose. A 10 mg-per-unit drug needs a conversion step first; this one doesn't — units equal the ordered mg directly.
| Dose | Units | Medicare drug allowed |
|---|---|---|
| 100 mg | 100 | $6,064.50 |
| 200 mg | 200 | $12,129.00 |
| 300 mg | 300 | $18,193.50 |
| 400 mg | 400 | $24,258.00 |
Keytruda is approved on two schedules — 200 mg every three weeks, or 400 mg every six weeks. Across a year they deliver almost the same amount of drug, so the annual allowed amount lands within a few percent either way. What changes is the size of one claim, and with it how much the patient has to find at once.
| Schedule | Allowed per claim | Patient owes, deductible met | Plan K owes, first claim | Reaches Plan K’s $8,000 cap |
|---|---|---|---|---|
| 200 mg every 3 weeks | $12,262.27 | $2,452.45 | $1,480.93 | 7th dose — week 18 |
| 400 mg every 6 weeks | $24,391.27 | $4,878.25 | $2,693.83 | 4th dose — week 18 |
Both schedules reach the Plan K out-of-pocket maximum in the same week of the year, because the yearly spend is the same. What the six-week schedule does is double every bill up to that point: a Plan K patient owes $2,693.83 at the first infusion rather than $1,480.93, on a treatment start where a foundation fund may not yet be open. That is a scheduling decision with a cash-flow consequence for the patient, and an annual-cost view hides it completely.
For a 200 mg dose (200 units) with the 96413 infusion code, Medicare allows $12,262.27, and the Part B coinsurance on that is $2,452.45. Plans A, B, C, D, F, G, M and N cover that coinsurance in full, so those patients owe nothing per cycle once the $283 deductible is met. Plans K and L do not, and at this claim size the gap compounds fast: a Plan K patient owes $1,226.23 every three weeks and crosses Plan K’s $8,000 annual out-of-pocket maximum on the seventh dose of the year, after which the plan covers the coinsurance in full and Keytruda costs that patient nothing more until January. See what each Medigap plan (A–N) owes on this claim →
| Plan | Covers Part B deductible ($283) | Covers Part B coinsurance | Patient owes, deductible met | Patient owes, deductible not met |
|---|---|---|---|---|
| Plan K | No | 50% | $1,226.23 | $1,480.93 |
| Plan L | No | 75% | $613.11 | $881.96 |
Only the letters that leave this patient a balance are listed. The full A–N grid, the high-deductible variants, Plan N’s office-visit carve-out and the MACRA restriction on Plans C and F are at Medigap Plans A–N.
Commercial payers negotiate their own rate for J9271, not ASP+6% — Aetna's median published rate is $60.86 per mg, essentially the same as Medicare's $60.645, putting a 200 mg dose at $12,172.00 before benefits. Full explanation: How commercial drug reimbursement works →
| Formulation | HCPCS | ASP+6% per mg | Standard dose | Drug allowed |
|---|---|---|---|---|
| Keytruda (IV) | J9271 | $60.645 | 200 mg q3w | $12,129.00 |
| Keytruda Qlex (SC) | J9277 | $31.94 | 395 mg q3w | $12,616.30 |
Qlex's per-mg rate is roughly half of J9271's, but its fixed dose (395 mg) is almost double 200 mg, so the two drug-allowed totals land close together. Administration costs differ more: Qlex's 1–2 minute subcutaneous injection bills 96401, not the 30-minute infusion's 96413, which changes the administration allowed amount and can move the visit out of an infusion suite entirely. J9277 carries no Medicare ASP history before Q2 2026.
Qlex also runs as 790 mg every 6 weeks and administers with 96401, not 96413. It bills under J9277, never J9271 — the two codes are not interchangeable on a claim.
| Quarter | ASP+6% per mg |
|---|---|
| 2025 Q1 | $57.603 |
| 2025 Q2 | $59.349 |
| 2025 Q3 | $58.562 |
| 2025 Q4 | $60.291 |
| 2026 Q1 | $59.726 |
| 2026 Q2 | $61.251 |
| 2026 Q3 (current) | $60.645 |
The Merck Co-pay Assistance Program for Keytruda covers commercially-insured patients down to $25 per administration, up to $25,000 per year — it excludes Medicare, Medicaid and other federal program patients. The Merck Patient Assistance Program provides Keytruda free of charge to uninsured and underinsured patients who meet income requirements. For Medicare patients, a diagnosis-matched oncology foundation fund (PAN Foundation, HealthWell Foundation, The Assistance Fund, Good Days) can cover the coinsurance up to its annual cap when one is open for that specific cancer type — CareCost watches fund status by diagnosis and flags one the moment it opens.
$60.645 per mg for Q3 2026 (ASP+6%). The standard 200 mg dose needs 200 units, so Medicare's allowed drug amount is $12,129.00.
For a 200 mg dose with the 96413 infusion administration code, Medicare allows $12,262.27 and the patient's 20% coinsurance is $2,452.45 after the Part B deductible is met. What each Medigap plan leaves on this claim ↓
Plan A and Plan B pay the full Part B coinsurance on this claim; because a single Keytruda dose is over $12,000, that's worth thousands of dollars a year rather than the tens or hundreds it would be on a cheaper drug. Full explanation: what every plan letter A–N covers →
The Merck Co-pay Assistance Program covers commercially-insured patients down to $25 per administration, up to $25,000 per year — it excludes Medicare and Medicaid. The Merck Patient Assistance Program provides free drug to uninsured and underinsured patients who qualify. Oncology foundation funds can cover the Medicare coinsurance by cancer type when a matching fund is open.
Aetna's median published rate for J9271 is $60.86 per mg, negotiated rather than tied to ASP+6%, and essentially the same as Medicare's $60.645. Full explanation: how contracted rates are set and why they vary by payer and state →
Select the payer and the state in the estimator above. It reads that payer’s own published price file for J9271 and returns the median allowed amount for that state, with the sample size it came from. Rates vary by state: Anthem’s median is $61.25 per mg in California and $63.11 in Maine. Check a payer →
No. A 30-minute Keytruda infusion bills 96413 alone — 96415 (each additional hour) does not apply. Full explanation: why administration is billed separately →
Compare the allowed reimbursement the estimator above shows against your own acquisition and administration costs — margin matters more here than on cheaper drugs given the $12,000+ dose size. CareCost estimates the allowed reimbursement only; it does not calculate acquisition cost or margin. See the estimate above ↑
Sources: CMS ASP pricing files (Q3 2026); Medicare physician fee schedule (96413, 99214, national non-facility); Medicare Part B deductible (2026); Medicare Rights Center 2026 Medigap plan benefits chart; 37 commercial payer published price files (Q2 2026); Merck Co-pay Assistance Program and Merck Patient Assistance Program terms (merckaccessprogram-keytruda.com, verified May 2026); oncology foundation fund terms and status (public/programs-bundle.js, generated from the live programs corpus).
Reviewed September 9, 2026 by Erin Rose, CareCost Estimate founder. Methodology →