Keytruda, Expected Out-of-Pocket Cost Reduced from 100 Million to 5 Million KRW with National Health Insurance Coverage

When Keytruda, known as the "miracle anticancer drug," is covered by the National Health Insurance, the out-of-pocket expenses for patients, which previously reached up to 100 million KRW per year, are expected to drop to around 5 million KRW.

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According to the government and related industries on the 18th, although there are differences depending on the type of cancer, the current annual out-of-pocket cost for Keytruda is between 70 million and 100 million KRW. However, if health insurance is applied, the out-of-pocket rate will be reduced to 5%, and the annual drug cost burden for patients is expected to be up to around 5 million KRW.

The significant reduction in out-of-pocket expenses is due to the government's Special Calculation Exception system. This system supports patients suffering from severe, rare, or intractable diseases by reducing their medical expenses burden.

When designated as a beneficiary of the Special Calculation Exception, the burden of medical and drug costs is greatly reduced, lowering the patient’s share of outpatient and inpatient medical fees and eligible drugs from the usual 20-30% to 5%. However, non-reimbursable items and nursing care costs are not covered.

Earlier, the Health Insurance Review and Assessment Service (HIRA) announced on the 12th that the Cancer Disease Deliberation Committee had reviewed the expansion of Keytruda’s reimbursement criteria and established reimbursement standards for a total of 11 indications (efficacies and effects).

The indications for which reimbursement criteria were set at this meeting include gastric or gastroesophageal junction adenocarcinoma, esophageal cancer, endometrial cancer, colorectal cancer, head and neck squamous cell carcinoma, cervical cancer, triple-negative breast cancer, small intestine cancer, and biliary tract cancer.

If this agenda passes the HIRA Drug Reimbursement Evaluation Committee in the future, it will undergo price negotiations with the National Health Insurance Service and deliberation by the Health Insurance Policy Deliberation Committee, after which additional health insurance coverage will be applied. If the price of Keytruda itself decreases during price negotiations, the out-of-pocket expenses may be further reduced.

According to MSD (Merck) in the United States, Keytruda is currently approved for a total of 18 cancer types and 34 indications in Korea. Of these, only 4 cancer types and 7 indications are covered by insurance reimbursement. If all 11 indications for which reimbursement criteria were set this time receive health insurance coverage, the total number of insurance-covered indications is expected to reach 18.

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