Does Medicare Cover Zejula? 

Ovarian cancer can affect women of all ages, but you may be surprised to learn that ovarian cancer is most prevalent in older women. According to the Ovarian Cancer Research Alliance, the median age for diagnosis of ovarian cancer is 63. Additionally, the American Cancer Society points out that ovarian cancer is most often found in women who are post-menopause.

These statistics indicate that most older women will want to have regular ovarian cancer screenings completed according to a schedule recommended by their doctors. Screening for ovarian cancer is also typically recommended if you have a family history of ovarian cancer or risk factors for developing the disease.

How is ovarian cancer treated?

If ovarian cancer is diagnosed, treatment options depend on the stage of the disease and any confounding health factors. Traditional cancer treatments like chemotherapy and surgery may be able to eradicate cancer cells, but prescription medications like Zejula may also be used to prevent a recurrence of cancer that has gone into remission. Hormone therapy may be prescribed to help women affected by ovarian cancer fight the side effects of cancer treatments that may disturb the balance of hormones like estrogen.

What is Zejula?

Zejula (niraparib) is a prescription medication used as a maintenance therapy for women who have been treated for advanced-stage ovarian cancer after the use of platinum-based chemotherapy. As a maintenance therapy, Zejula does not treat cancer directly. Instead, it is a preventative medication that is designed to stop cancer from recurring.

Zejula works by inhibiting poly [ADP-ribose] polymerase (PARP). This is an enzyme associated with tumor suppression alongside breast cancer genes (BRCA) one and two. There are also two different PARP enzymes, and these are numbered one and two as well.  

Does Medicare cover Zejula?

Medicare benefits cover Zejula under Medicare Part D, the prescription drug benefit. Medicare recipients who carry Part D coverage can learn more about their coverage limitations and costs by exploring the formulary that is included with each Medicare prescription drug plan. Your plan’s formulary provides information about which drugs are covered by your Medicare benefits, and it also explains the differences in coverage for brand names versus generics.

Since Medicare Part D requires that all covered prescriptions be available for purchase from a retail drug store, you may face a copay for each prescription you pick up. The specifics of your copay costs are outlined in your plan literature.

Medicare Part D also requires a monthly premium, and Medicare recipients who carry Part D coverage must meet their annual deductible before prescription drug benefits begin to pay for covered medications. The cost of your Medicare premium for Part D coverage is based on your income. Those with higher incomes can expect to pay an additional premium on top of the plan premium for prescription drug coverage.

Medicare coverage for Zejula in an outpatient setting

Zejula is a pill that is taken at home following ovarian cancer treatment, so odds are likely that Medicare recipients will only take Zejula in this fashion. There may, however, be times when Zejula is administered in a clinical setting.

In these situations, Medicare benefits cover Zejula under Part B of Medicare. Part B covers outpatient care and pays 80% of the cost of clinical services, durable medical equipment (DME) and diagnostic testing. Unlike Medicare Part A which has no premium for most Medicare recipients, Part B does require a monthly premium, and a separate deductible applies.

Medicare coverage for Zejula in an inpatient setting

If you are prescribed Zejula as part of an inpatient admittance at a Medicare-approved inpatient facility, Medicare benefits will cover your prescription during your stay. Inpatient care, including your stay and medical treatment, receives coverage through Medicare Part A. You can receive inpatient coverage for a total of 60 days in a Medicare-participating hospital or 20 days in a Medicare-participating skilled nursing facility each benefit period.

These are the base benefits of Medicare Part A, but additional days may be available at a per-day rate. If you have been treated for ovarian cancer and have been admitted to a hospital in the last year, it would be a good idea to check with your benefits administrator periodically to see how many days of inpatient care you have remaining. This can give you peace of mind or help you plan for emergencies before they happen.

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