Are low-volume PEG preps covered by Medicare?

In this article:

• What are low-volume PEG preps?
• Does Medicare cover low-volume PEG preps?
• How much do low-volume PEG preps cost with Medicare?
• Why do Medicare patients pay more for low-volume preps?
• How to lower the cost of colonoscopy prep with Medicare
• Expert takeaway
• FAQs

In this article

• What are low-volume PEG preps?
• Does Medicare cover low-volume PEG preps?
• How much do low-volume PEG preps cost with Medicare?
• Why do Medicare patients pay more for low-volume preps?
• How to lower the cost of colonoscopy prep with Medicare
• Expert takeaway
• FAQs

Since Medicare covers colonoscopies, you might think it also covers all types of colonoscopy prep, but that’s not always the case. Although Medicare Part D generally will cover colonoscopy prep kits, coverage varies by plan. As such, one type of kit may be fully covered, while another type of kit may require some cost-sharing. Some people prefer low-volume prep kits, since they require you to drink much less fluid than traditional prep kits do, but it’s important to know how much they’ll actually cost. We’ve got all the details on what Medicare Part D might cover, how much patients pay, and how to save money.

What are low-volume PEG preps?

Polyethylene glycol (PEG) is an osmotic laxative that works by pulling water into the intestines, which softens the stool and makes bowel movements easier. It’s an essential process for colonoscopies, since it clears out all the stool and residue, allowing the healthcare provider to get an unobstructed view of the colon.

Traditional high-volume colonoscopy prep kits have required patients to drink 4 full liters of bowel prep solution (around a gallon). These kits include both laxatives and electrolytes to help prevent dehydration when the bowel clears. Low-volume prep kits are a more modern solution, usually requiring less than 1–2 liters instead, which is easier for the patient. MoviPrep and Plenvu are two of the most common low-volume PEG-based kits, while some other low-volume (non-PEG-based) options include Clenpiq, Sutab (oral tablets), and Suprep.

Patients previously had to drink all the medications and required fluids the night before their procedure, but it’s recently become more common to split it up. “I advocate for a split-dose regimen that is evidence-based and used at high-quality gastroenterology practices nationwide: Patients drink the first dose the evening prior to the colonoscopy and the second dose early in the morning, exactly four to five hours before their scheduled arrival,” says Savita Srivastava, MD, gastroenterologist and microbiome specialist. “I stress that they must consume the required clear liquids alongside the low-volume solution, as the hyperosmotic nature of these preps relies on supplemental hydration to effectively clear the mucosal wall and balance electrolytes.”

Does Medicare cover low-volume PEG preps?

Even though the Affordable Care Act requires coverage for colonoscopy screenings and bowel preparation kits without cost-sharing, many people still have to pay for their low-volume PEG preps. In fact, according to the American Gastroenterological Association, 83% of Medicare claims for colonoscopy prep kits come with out-of-pocket costs.

Does Medicare Part D cover low-volume PEG preps?

Because PEG preps are medications you fill at a pharmacy and take at home, they usually fall under Medicare Part D, which covers prescription drugs. Part D plans may cover part of the cost, but it’s not a guarantee. “ In practice, the vast majority of my patients face steep tier-copays or high deductibles for brand-name low-volume preps, sometimes paying over $100 out of pocket,” Dr. Srivastava says. “Coverage is almost entirely dependent on the specific insurer’s formulary tiers and whether the patient has met their annual Part D deductible.”

Medicare spent over $8 million on Plenvu coverage and $73,000 on MoviPrep coverage in 2023, which are significant amounts. But that breaks down to around $49 per dose for Plenvu and $131 for MoviPrep. Seeing as the average prices are $209 and $179, respectively, most people still have to pay a portion.

That’s because many Medicare Part D plans place brand-name low-volume PEG preps in the higher tiers of their formularies. The lower tiers of any insurance plan are reserved for generics and preferred drugs, which have much lower copays, while drugs from higher tiers cost the patient more. Of course, every plan has its own policies and cost structures, so the tier system and copay amounts can vary.

Does Medicare Part B cover colonoscopy prep?

Medicare Part B, for the most part, is specifically for in-office procedures and treatments. In this case, that includes the colonoscopy itself and the required anesthesia. As prescription drugs, colonoscopy preparation kits aren’t administered in the healthcare provider’s office, so Part B won’t cover them.

Does Medicare Advantage cover low-volume preps?

Medicare Advantage (sometimes referred to as “Medicare Part C”) is a combination of Part A, Part B, and usually Part D, depending on the plan. The plans that include Part D will likely provide some coverage for colonoscopy prep, but the ones that lack Part D will not. Some plans might have better cost-sharing policies than standalone Part D plans, but coverage varies. Check your plan’s formulary on Medicare.gov (using the Plan Finder tool) to see if your plan will cover PEG prep kits.

How much do low-volume PEG preps cost with Medicare?

According to the Colon Cancer Coalition, the median cost of low-volume preps after Medicare coverage is around $56, while the average cost of high-volume preps is $8. These are not exact numbers, though, and out-of-pocket costs can be higher or lower, depending on the specific plan.

Why do Medicare patients pay more for low-volume preps?

There are a few reasons why low-volume preps cost more than traditional high-volume ones. The biggest is that Medicare Part D plans often label low-volume preps as specialty drugs, placing them in the higher tiers of their formularies, where copays are higher. Second, some low-volume preps have additional active ingredients, making their production and research more expensive, potentially increasing their retail prices. Additionally, some low-volume preps, like Plenvu, don’t have an FDA-approved generic version, so the more expensive brand name is the only option.

Unexpected out-of-pocket costs have consequences that go beyond the wallet. Research indicates that they make patients less likely to comply with treatment, which could decrease the effectiveness of the colonoscopy procedure. That’s why the American Gastroenterological Association and American Society for Gastrointestinal Endoscopy are lobbying to eliminate cost-sharing policies for these drugs from Medicare Part D plans. Some states have also passed legislation that requires health plans to cover colonoscopy prep costs.

How to lower the cost of colonoscopy prep with Medicare

If you’re stuck with out-of-pocket costs for your PEG prep kit, or your Medicare Part D plan won’t cover it at all, you’re not out of luck. Here are a few other ways you can save:

1. Use a SingleCare prescription discount coupon. These coupons are free and they can significantly lower the price of colonoscopy prep kits. Although you can’t combine SingleCare discounts with Medicare Part D coverage, using a SingleCare coupon could reduce your out-of-pocket cost more than your Part D plan does. Check your formulary and the current SingleCare price to compare.
2. Ask your healthcare provider to prescribe a covered alternative. Medicare prescription plans may prefer one brand or type of prep kit over another, so if you’re paying a lot out of pocket, ask if you can get one that your plan will cover more comprehensively. “My primary go-to alternative is a high-volume generic PEG-3350 with electrolytes (like generic GoLYTELY), which is universally covered or available for a very low copay,” Dr. Srivastava says.
3. Request a formulary exception. For some patients, like those who have difficulty swallowing, for example, a low-volume kit might be medically necessary. If that’s you, your healthcare provider can submit documentation to possibly get your plan to make an exception.

Expert takeaway

“If you are interested in trying a low-volume bowel prep, ask your healthcare provider to check your formulary. If it’s not covered, a higher-volume prep may be a good alternative,” says Karen Berger, Pharm.D., member of the SingleCare Medical Review Board. “However, if you think you may have trouble with large amounts of bowel prep solution, you may want to look into manufacturer coupons or consider paying out-of-pocket for the low-volume prep.”

Frequently asked questions

Which colonoscopy prep has the least amount of liquid to drink?

Clenpiq has only two 6-ounce doses, but you need to accompany the first dose with 40 ounces of water and the second one with 32 ounces. Sutab comes in pill form, so there’s no liquid bowel prep involved, but you still have to drink 96 oz of water in total.

Does Medicare cover colonoscopy preps?

Medicare Part D often covers colonoscopy preps, but it depends on the specific plan. Even when it’s covered, patients still might have out-of-pocket costs based on the plan’s cost-sharing policy. Medicare Part B generally does not cover colonoscopy prep.

How often will Medicare cover colonoscopies?

For people who have a high risk of colorectal cancer, Medicare Part B will cover a colonoscopy once every 24 months. Everyone else will receive coverage for one colonoscopy procedure every 120 months, or 48 months after a previous flexible sigmoidoscopy.