Xtandi is the brand name for enzalutamide, an androgen receptor inhibitor co-developed and co-promoted by Astellas Pharma and Pfizer. The FDA has approved Xtandi for multiple prostate cancer settings: metastatic castration-resistant prostate cancer (mCRPC), metastatic castration-sensitive prostate cancer (mCSPC), non-metastatic castration-resistant prostate cancer (nmCRPC), and most recently, non-metastatic castration-sensitive prostate cancer with high-risk biochemical recurrence (nmCSPC, approved November 2023). Xtandi works by blocking androgen receptors, reducing the growth signal that testosterone sends to prostate cancer cells.
Xtandi's 2026 list price of approximately $15,353 per month reflects the drug's lack of generic competition and its status as a specialty oncology medication dispensed exclusively through specialty pharmacies such as CVS Specialty, Accredo, Onco360, Kroger Specialty, and OptumRx. Patients pay this list price only in the rare case of having no insurance coverage, no manufacturer savings card, and no patient assistance program eligibility. For most insured patients, the Inflation Reduction Act's $2,000 annual Part D out-of-pocket cap in 2026 is the most important number to understand. For commercially insured patients, the Xtandi Patient Savings Program can reduce cost-sharing to as little as $0 per prescription, subject to a $7,000 annual maximum.
Under the Inflation Reduction Act of 2022, the Centers for Medicare and Medicaid Services selected enzalutamide (Xtandi) in the second round of Medicare drug price negotiations in January 2025. Negotiations concluded in November 2025 and the negotiated Maximum Fair Price of $7,004 per 30-day supply takes effect January 1, 2027. Once that negotiated price is active, Medicare beneficiaries with prostate cancer will see substantially lower cost-sharing. Patients currently on Xtandi should also review whether Medicare Extra Help (Low Income Subsidy) further reduces their out-of-pocket costs below the $2,000 annual cap for 2026. For more information on how Medicaid covers prostate cancer drugs in your state, the federal poverty level thresholds used by the Astellas PAP, and the 2026 Medicare Part D benefit design, see the sources section below.
What Xtandi Costs by Point of Pay (2026)
The price you pay depends almost entirely on WHERE you pay. The same xtandi can cost many times more at a hospital than at your local pharmacy:
2026 Xtandi Price by Point of Pay| Where you pay | Typical cost | Notes |
|---|
| Specialty pharmacy (retail, cash, no insurance) | $15,000 - $15,500/month | List price for 120 capsules (40 mg), 30-day supply. Dispensed only at authorized specialty pharmacies. |
| Medicare Part D (2026) | $0 - $2,000/year (OOP cap applies) | 100% of Medicare Part D plans cover Xtandi. Once you reach $2,000 in annual out-of-pocket Part D spending, you pay $0 for the rest of the year. |
| Commercial insurance with Xtandi Savings Program | $0/prescription (up to $7,000/year) | For commercially insured patients only. Savings card not valid with Medicare, Medicaid, or VA coverage. |
| Medicaid | $0 - $4/prescription (with prior authorization) | Most state Medicaid programs cover Xtandi for FDA-approved prostate cancer indications with prior authorization. Nominal copay varies by state. |
| Uninsured (Astellas PAP) | $0 (free, if you meet PAP financial eligibility) | Astellas Patient Assistance Program provides Xtandi at no cost to uninsured US residents with verified financial need. |
Retail list price reflects 2026 Xtandi pricing per xtandipricing.com. Part D ranges depend on your plan formulary tier and where you are in your benefit year. Specialty pharmacy cash prices may vary slightly by dispensing pharmacy.
Source: Xtandi Pricing Information (xtandipricing.com), CMS Part D 2026 benefit design, Astellas Pharma Support Solutions
Why Hospitals Charge So Much
Xtandi is rarely dispensed in an inpatient hospital setting because it is a self-administered oral medication taken at home. Patients typically receive a 30-day supply through an authorized specialty pharmacy and self-administer Xtandi at home as four 40 mg capsules (or two 80 mg tablets) once daily. When Xtandi does appear on an inpatient or outpatient hospital bill, it is usually because the patient was admitted while undergoing active treatment and the hospital's pharmacy supplied the medication during the stay.
Hospital pharmacy markups on specialty oncology drugs like Xtandi can be severe. A 30-day supply purchased through a hospital's inpatient pharmacy can be billed at $25,000 to $45,000, compared to the $15,353 list price at a specialty outpatient pharmacy. Three structural factors drive this: the hospital's cost of drug acquisition at non-negotiated rates, facility fees layered onto every drug-dispensing event, and administrative overhead charged per fill. If you receive an itemized hospital bill showing Xtandi at more than $18,000 for a single month's supply, request the NDC code for the dispensed drug, compare it to the 2026 wholesale acquisition cost (approximately $15,353), and file a formal dispute with your insurance plan if the charge exceeds what your formulary or explanation of benefits specifies.
Patients receiving Xtandi under commercial insurance or Medicare Part D should always have their prescription routed to an authorized network specialty pharmacy rather than a hospital outpatient pharmacy, unless the hospital is in-network for specialty pharmacy dispensing. Out-of-network specialty pharmacy fills can result in claims being denied entirely or applied at non-preferred cost-sharing rates, leaving patients responsible for a larger share of the $15,353 monthly cost. Confirming your specialty pharmacy network status before the first fill is one of the most important steps in managing Xtandi costs in 2026.
Patient Assistance Programs
Astellas Pharma runs two primary financial support programs for Xtandi patients. The Xtandi Patient Savings Program is for commercially insured patients and can reduce copays to $0 per prescription (up to $7,000 per year). The Astellas Patient Assistance Program provides free Xtandi to uninsured or underinsured patients who meet financial eligibility requirements. Without any assistance, the 2026 list price of $15,353 per month makes Xtandi unaffordable for uninsured patients. The patient assistance program is specifically designed to bridge that gap for income-eligible patients.
Patient assistance programs for Xtandi| Manufacturer program | Cost / Benefit | How to apply |
|---|
| Xtandi Patient Savings Program (Astellas / Pfizer, commercially insured) | $0 per prescription for commercially insured patients; maximum $7,000 assistance per calendar year | xtandi.com/financial-support |
| Astellas Patient Assistance Program (PAP, uninsured/underinsured) | Free Xtandi for uninsured US residents who meet financial eligibility requirements (income-based, typically up to 400% FPL) | astellaspharmasupportsolutions.com/patient/xtandi |
| NeedyMeds Drug Discount Card | Variable discount accepted at participating specialty pharmacies; free to obtain at needymeds.org | needymeds.org |
Manufacturer savings cards and copay assistance programs (including the Xtandi Patient Savings Program) cannot be used by patients whose prescriptions are reimbursed by Medicare, Medicaid, Medigap, TRICARE, the Department of Defense, the Department of Veterans Affairs, or any other state or federal government health care program. This is required by federal anti-kickback statute (42 U.S.C. § 1320a-7b). If you have Medicare or Medicaid, apply for the Astellas Patient Assistance Program or ask your oncology social worker about independent co-pay assistance foundations (such as the Patient Advocate Foundation or CancerCare).
Source: Astellas Pharma Support Solutions (astellaspharmasupportsolutions.com), xtandi.com/financial-support, NeedyMeds.org
Medicare Part D
Xtandi is a Medicare Part D specialty oral drug. For 2026, every Medicare Part D plan covers Xtandi for FDA-approved prostate cancer indications. According to Astellas, 100% of Medicare Part D patients are covered for Xtandi. Your specific monthly cost-sharing depends on your plan's formulary tier placement and where you are in the benefit year (deductible phase, initial coverage phase, or catastrophic phase). However, the most important anchor fact for 2026 is the $2,000 annual out-of-pocket cap: once you spend $2,000 on all Part D drugs combined in a calendar year, you pay $0 for covered drugs for the rest of that year.
Patients with Medicare who pay the full standard Part D cost-sharing on a $15,353/month specialty drug will typically reach the $2,000 annual out-of-pocket cap within the first 2 to 3 months of the benefit year. At that point, covered Xtandi fills are free for the balance of the calendar year. The 2026 $2,000 cap replaced the old catastrophic-phase coinsurance that previously exposed patients to unlimited cost-sharing above the coverage gap. Patients who qualify for Medicare Extra Help (the Low Income Subsidy) may have even lower out-of-pocket costs, often $0 to $11.20 per fill in 2026, depending on income. To check Extra Help eligibility, visit medicare.gov or call 1-800-MEDICARE.
Medicare Prescription Payment Plan (M3P), available starting in 2025, allows Part D enrollees to spread their annual out-of-pocket costs across monthly installments rather than paying a large lump sum early in the year when deductibles and initial coverage phase costs are highest. For Xtandi patients who hit the $2,000 cap early, this plan can smooth cash flow. Ask your Part D plan about M3P enrollment if a single Xtandi fill triggers a large upfront cost-sharing amount. The formulary tier placement for Xtandi most commonly falls on the specialty tier (Tier 5), which carries the highest cost-sharing percentage before reaching the annual cap.
Common Xtandi Billing Errors
Xtandi billing errors most commonly occur at the specialty pharmacy level, at the point of prior authorization, and when transitioning insurance mid-year. If your bill appears higher than expected, check for these issues before paying:
- Prior authorization not submitted or renewed: most commercial plans and Medicaid require PA for Xtandi annually. If your PA lapsed or was not filed, you may be charged the full list price ($15,353) at the specialty pharmacy.
- Xtandi Patient Savings Program (manufacturer coupon) not applied: if you are commercially insured, confirm with the specialty pharmacy that the savings card BIN/PCN has been entered correctly. The manufacturer coupon can reduce your cost to $0.
- Wrong specialty pharmacy network: using an out-of-network specialty pharmacy can cause the claim to be rejected or billed at a much higher cost-sharing rate. Confirm your plan's in-network specialty pharmacy list before each fill.
- Billed past the $2,000 Part D out-of-pocket cap: if you have Medicare Part D and have already spent $2,000 out-of-pocket in 2026, you owe $0 for further covered fills. If the pharmacy bills you beyond that cap, contact your Part D plan immediately.
- Step therapy denial without appeal: some plans require you to try lower-cost prostate cancer drugs (such as bicalutamide) before approving Xtandi. If your prescriber has documented clinical reasons why step therapy is inappropriate, a peer-to-peer review or step-therapy exception can override this requirement.
Frequently Asked Questions
Is there a generic for Xtandi (enzalutamide) in 2026?
No. As of 2026, no FDA-approved generic for enzalutamide (Xtandi) is available in the United States. Multiple manufacturers have received tentative FDA approval for generic enzalutamide, meaning the drugs meet safety and efficacy standards but cannot launch until Xtandi's key composition-of-matter patents expire. The last major US patent expires in August 2027. A patent settlement between Astellas/Pfizer and Sun Pharmaceutical cleared the path for a potential generic launch in late 2027 or 2028. Once generic enzalutamide launches, the price is expected to fall 70 to 90 percent from the current $15,353/month list price.
How do I apply for the Astellas Patient Assistance Program for Xtandi?
Call Xtandi Support Solutions at 1-855-898-2634 (Monday through Friday, 8 AM to 8 PM ET) or visit astellaspharmasupportsolutions.com to start the application. You will need: proof of household income (tax return or pay stubs), proof of US residency, a valid Xtandi prescription from your oncologist, and documentation that you are uninsured or lack adequate prescription drug coverage. Both a patient section and a prescriber section of the form must be signed. Processing takes 5 to 10 business days. If approved, Xtandi is shipped free to your home or oncologist's office. The program typically covers uninsured patients with incomes up to approximately 400% of the federal poverty level.
Can I use the Xtandi savings card with Medicare?
No. Federal anti-kickback law (42 U.S.C. § 1320a-7b) bars manufacturer copay cards from being used by anyone whose prescription is reimbursed by Medicare, Medicaid, TRICARE, the VA, or any other federal or state government health program. The Xtandi Patient Savings Program is available only to patients with commercial (private) insurance. If you are on Medicare, your primary cost-control tools are the $2,000 annual Part D out-of-pocket cap (after which you pay $0 for covered drugs), Medicare Extra Help (Low Income Subsidy) if you qualify based on income, and the Astellas Patient Assistance Program if you have inadequate coverage. Call 1-800-MEDICARE to check Extra Help eligibility.
What if my insurance denies coverage for Xtandi?
Start by requesting a written denial notice with the specific reason. File a formal appeal within 60 days and have your oncologist attach a letter of medical necessity citing your prostate cancer stage and treatment history. Ask your oncologist to request a peer-to-peer review with the plan's medical director. If the internal appeal fails, escalate to external independent review through your state Department of Insurance (commercial) or the Medicare Appeals Council (Part D). If all appeals fail, apply for the Astellas Patient Assistance Program, which can provide Xtandi free to uninsured and underinsured income-eligible patients.
Does the IRA Medicare negotiation apply to Xtandi in 2026?
Not yet in 2026. Xtandi (enzalutamide) is one of 15 drugs selected by CMS for the second round of Medicare price negotiations under the Inflation Reduction Act of 2022. Negotiations concluded in November 2025 and the negotiated Maximum Fair Price of $7,004 per 30-day supply takes effect January 1, 2027. In 2026, Medicare Part D patients pay based on their plan formulary and the $2,000 annual out-of-pocket cap. Starting in 2027, Medicare beneficiaries will pay no more than the $7,004 Maximum Fair Price per month, a reduction of approximately 54 percent from the 2026 list price of $15,353.
What does Xtandi cost without insurance in 2026?
The 2026 list price for Xtandi is approximately $15,353 per month for a 30-day supply (120 capsules at 40 mg each), according to xtandipricing.com. Xtandi is dispensed only through authorized specialty pharmacies, and cash prices are essentially uniform at the list price since there is no generic competition. GoodRx and similar discount programs typically have limited pricing leverage on specialty oncology drugs with limited-distribution networks. If you are uninsured, the most effective cost-reduction option is the Astellas Patient Assistance Program, which can provide Xtandi free if you meet financial eligibility requirements.
Do I qualify for the Astellas Patient Assistance Program for Xtandi?
The Astellas Patient Assistance Program (PAP) provides free Xtandi to uninsured and underinsured US residents who meet program financial eligibility requirements. Income eligibility is typically expressed as a percentage of the federal poverty level (approximately up to 400% FPL). For a household of one in 2026, 400% FPL equals $63,840 in annual income. For a household of four, it equals $132,000. Non-income requirements include: being a US resident with a verifiable shipping address, having a valid Xtandi prescription for an FDA-approved indication, and not having other qualifying prescription drug insurance coverage. Patients with Medicare Part D who cannot afford cost-sharing may also qualify for certain program tiers. Call 1-855-898-2634 for a definitive eligibility determination.
What is the IRA Round 2 Maximum Fair Price for Xtandi and when does it start?
Under the Inflation Reduction Act of 2022, CMS negotiated a Maximum Fair Price of $7,004 per 30-day supply for Xtandi (enzalutamide). This negotiated price is effective January 1, 2027, covering Medicare Part D beneficiaries who fill Xtandi at any participating pharmacy. The list price before negotiation is approximately $15,353 per month in 2026, making the Maximum Fair Price a reduction of approximately 54 percent. Starting in 2027, Medicare patients will pay no more than their applicable cost-sharing on the $7,004 MFP rather than on the $15,353 list price, which will significantly reduce out-of-pocket spending before reaching the annual Part D cap. This is the first time CMS has negotiated the price of an oral prostate cancer drug under the IRA.
