Just a few weeks after President Donald Trump’s December promise that prescription drug prices would plummet “fast and furious,” Patricia Brown checked into a California clinic for an infusion of Merck & Co.’s blockbuster cancer drug, Keytruda.
When the bill arrived, the clinic’s charge for a 400 mg dose dominated the page: $162,567.74.
Brown, an accomplished cook battling lung cancer, owed about $2,000.
But the six-figure charges to Brown and her insurance company show how quickly prices for cutting-edge medical treatments can balloon in the U.S. health care system. Someone has to pay: An employer, taxpayers, or regular people whose insurance premiums go up and up.
The price of Keytruda for Americans starts high and often heads higher. Merck lists Brown’s dose at an already steep $24,000. Then, depending on the insurer, the health-care provider and any number of middlemen, prices can rise.
Merck CEO and Chairman Robert M. Davis lined up behind Trump in December alongside the pharmaceutical leaders at a White House press conference. He declared 100% support for the president’s actions and vowed Merck would drop prices on a diabetes drug and a cardiovascular pill.
He didn’t say anything about cutting the cost of Keytruda, which accounted for $31.7 billion in worldwide sales in 2025, nearly half of Merck’s revenue.
The drug has become a lifeline for a growing number of cancer patients around the world. But a joint investigation by the International Consortium of Investigative Journalists and USA TODAY found that Merck has employed several tactics to keep Keytruda’s price high — along with its profits.
Merck protects the drug from generic competition behind a growing wall of patents. The company lobbies to avoid negotiating the price of the drug with Medicare. And though studies have said lower doses based on weight are effective and would save money, the company has not moved to change dosing.
In some other countries, ICIJ found, such tactics have priced Keytruda out of reach of cancer patients who need it. In the U.S., where Merck tallies about 60% of the drug’s sales, the prices generally begin with what Merck charges. Costs for the life-saving drug then increase as middlemen and health providers tack on charges.
In a statement, Merck spokeswoman Julie Cunningham blamed high prices in the U.S. on pharmacy benefit managers and health insurers, middle players who extract rebates and fees, driving up costs for patients.
“America is the only country in the world where entities that don’t make medicines take half of every dollar spent on brand medicines,” she said.
Merck’s tactics with Keytruda are common — and legal — in the pharmaceutical industry. Once a drug company discovers an effective medicine that the public and the medical community demand, the company pulls legal levers to maintain that advantage for as long as it can.
“Squeezing as much life out of an original patent is par for the course” in the drug industry, said Antonio Ciaccia, president of 3 Axis Advisors and an expert in drug pricing. “You get a breadwinner, you want to hold onto that breadwinner as long as you can.”
Scott Brown, a 63-year-old grocery store employee, has been caring for his wife, Patricia Brown, at their home in Rancho Cordova, California, for nearly a year as she fights advanced lung cancer that has spread to her brain and spine.
The couple, who have been together for 40 years, briefly turned to Keytruda in November 2025 alongside chemotherapy and radiation. Patricia Brown received the drug every six weeks until side effects on her thyroid forced her to stop. Looking at the bills, including the $162,000 bill for one Keytruda treatment from UC Davis Health, Scott Brown doubts prices for cancer treatment will ever fall.
“I would love for them to understand what the little guy’s going through,” he said of politicians and pharmaceutical executives, “but I’m also a realist.”
How Merck Protects Keytruda’s Price
Merck, either alone or jointly through partners, has employed the patent system to build a fortress around Keytruda of 50 active patents in the United States. Citing data from the Initiative for Medicines, Access, and Knowledge (I-MAK), ICIJ tracked more than 1,200 patent applications filed by Merck and other cancer research businesses across 53 countries, regions and territories. These patents could help Merck fend off competition and maintain high prices for 14 years after its original patents expire in 2028, ICIJ found.
In a statement, Merck’s Cunningham disputed those findings, calling it a “common myth” that drug companies game the patent system with overlapping patents to delay competition. “It has been repeatedly shown that patent counts do not predict timing of generic entry,” she said.
Patents are a critical part of the U.S. drug development system. In exchange for encouraging research and development of new drugs, patents allow companies an exclusive window to sell a brand name drug without competition from a less-expensive generic or biosimilar — generally lasting 20 years from the application date.
“This scenario where a drug company obtains dozens of patents protecting different aspects of a blockbuster drug in order to ward off competition is quite common,” said Dr. Benjamin Rome, a Harvard Medical School professor. “Just the existence of this patent thicket can scare away companies who would otherwise seek to make biosimilar versions of Keytruda, as the biosimilar makers need to spend exorbitant amounts of money to fight these patents in court.”
Merck is also rolling out a new injectable version called Keytruda Qlex, expecting 30% to 40% of users to switch before the original patent expires in 2028 — a move that could delay generic competition until the 2030s, ICIJ reported, citing three industry experts.
While the Food and Drug Administration has approved Keytruda’s dosing of 200 mg every three weeks or 400 mg every six weeks, some cancer researchers contend Merck promotes a higher dosage than is necessary. The excess dosing could cost each patient an extra $75,000 over the course of their treatment, researchers at the World Health Organization say, totaling an estimated $5 billion that could be saved through 2040 just among lung cancer patients.
And like other drug companies, Merck has lobbied and sued to prevent Medicare from negotiating lower drug prices. The Inflation Reduction Act empowered Medicare to negotiate prices on some of its costliest drugs — but President Trump’s 2025 tax and spending legislation delayed those negotiations for drugs including Keytruda by at least one year.
Merck senior vice president Johanna Herrmann defended the company’s pricing practices, saying that Keytruda’s price “reflects its value to patients and health-care systems” and that the company is working to ensure health care is “affordable, efficient, equitable and sustainable on a global scale.”
Rates for Keytruda Vary by Tens of Thousands of Dollars
Beyond Merck’s list price of $12,031 per 200 mg treatment, the amount Americans actually pay is a spin of the wheel — depending on where they live, where they get it and what their insurance covers.
Interviews with patients and a review of drug price transparency data show actual billed rates vary by tens of thousands of dollars per treatment. Patients interviewed by USA TODAY shared hospital bills ranging from about $15,000 for a standard 200 mg treatment to more than $162,000 for Patricia Brown’s double dose — almost seven times Merck’s list price.
Brown’s insurer, UnitedHealthcare, paid more than $110,000 to UC Davis Health and discounted the bill by more than $57,000, a hospital invoice shows.
Data from Serif Health, a San Francisco firm that compiles records from more than 200 commercial insurers, shows negotiated in-network rates for a standard 200 mg Keytruda treatment range broadly by state. In Maine and Rhode Island, most patients are charged within a few hundred dollars of each other. In Alaska, Idaho and Utah, one patient could easily be billed thousands of dollars more than a neighbor with different insurance.
Overall, the majority of negotiated prices fall between $8,600 and $22,200 for a single treatment, with some extreme prices reported above $100,000 per dose.
Most insured patients — through employers or Medicare — pay only a sliver out of pocket until hitting their plan’s out-of-pocket maximum. For uninsured cancer patients, some hospital systems, nonprofits and Merck itself offer financial assistance programs.
Hospitals Charge Higher Prices
Barbara Thornton, a 64-year-old from Cincinnati, raised about $3,000 for pancreatic cancer research at a bake sale in her front yard last year — shortly after ringing the bell signaling she was 100% cancer-free.
Every three weeks for more than two years, she had driven a few streets over to a hospital outpatient clinic for Keytruda treatments. “Basically, that day at the infusion center was $42,000, and I was getting that every three weeks,” Thornton said. “But I was lucky. I had insurance.”
Her experience is common. Billed prices can nearly double when Keytruda is administered in a hospital outpatient setting versus a doctor’s office, according to the Health Care Cost Institute. The nonprofit found the median price for a dose at hospital systems was about $21,600 in 2022 — compared to $11,500 at doctor’s offices.
“The price tag depends entirely on the building you’re treated in,” said John Hargraves, HCCI’s managing director of data strategy and analytics. “The scale of spending we’re seeing here is remarkable and raises important questions about affordability for employers and patients alike.”
For a three-week regimen, 372 hospitals in 49 states charge more than 11,000 different prices for the same medication, according to an analysis by 3 Axis Advisors and Patient Rights Advocate. Even within the same hospital, prices vary significantly — at one Missouri hospital, the same drug could cost as little as $11,747 or as much as $42,498 depending solely on the patient’s insurance card.
Some Hospitals Cash In on Keytruda Discounts
Former North Carolina Treasurer Dale Folwell commissioned a report to examine why the state’s cancer drug costs soared 75% from 2018 through 2022. The answer pointed partly to the federal “340B” program.
Created in 1992 and expanded under the Affordable Care Act, 340B requires pharmaceutical companies to sell drugs at a discount to hospitals and clinics serving large shares of low-income and rural patients. Those hospitals can then charge market prices to insurers and patients.
The North Carolina report found that hospitals charged prices 5.4 times more than what they paid for cancer drugs under the program. For a single Keytruda treatment, hospitals collected an average payment of about $21,000 for medication they acquired for an estimated $8,000 — a profit of more than $13,000 per treatment.
“We could easily talk billions,” said Folwell. “But the fact is any one dollar stolen from any North Carolina taxpayer or citizen is one dollar too much.”
Collectively, hospitals and clinics spent nearly $8.2 billion on Keytruda in 2024 through the 340B program — by far the top-grossing drug in the federal program, nearly double the No. 2 drug.
Critics say some hospitals are extending the program to wealthier communities, buying drugs at a deep discount and then billing patients with robust insurance at full market rates.
‘Everyone Is Fighting for Their Life’
Brett Shoopman, a golf professional in Palm Springs, California, was surprised when a mole on his belly turned out to be Stage 4 melanoma. When his skin cancer returned after surgery, he began a year of Keytruda treatments — about $15,000 per infusion every three weeks.
“For a golf pro, that’s a lot of golf lessons!” Shoopman said. “Obviously, you don’t really know the costs right up front because you’re going to get their help because you have no alternative.”
Like Brown and Thornton, Shoopman’s insurance covered most of his costs. But as he noted, those costs don’t disappear — they’re borne by consumers, employers and taxpayers who absorb ever-rising premiums based on the nation’s more than $5 trillion in annual health care spending.
A friend created a GoFundMe to help cover Shoopman’s share of the bill. Now in its 13th year, his annual charity golf tournament has raised over $400,000 and funded free skin cancer screenings that have saved at least 15 lives.
“When you’re in a room like that, everyone is fighting for their life. It’s the saddest place to be,” Shoopman said. “Golf’s a challenge, but it’s nowhere near what cancer is.”
Editor’s Note: Some ICIJ funders advocate for reform of the pharmaceutical industry to make it more transparent and its products more affordable and accessible for patients. Funders have no involvement in ICIJ’s editorial decisions.
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