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Does Medicare cover chemo?

Medicare covers chemotherapy, but you’ll still owe a deductible and coinsurance
Lindsay Malzone writer headshot
By | Updated on Jan. 18, 2024 Medically reviewed by Scott Dershowitz, LMSW, CMC

Does Medicare cover chemotherapy? | What if my chemo treatments are denied by Medicare? | How much does chemotherapy cost with Medicare? | Ways to save on chemotherapy

More than 14% of Medicare beneficiaries have received a cancer diagnosis, according to the Leukemia & Lymphoma Society. Medicare beneficiaries older than age 65 accounted for 54% of all new cancer patients, according to the American Cancer Society in 2011. Therefore, it’s important for Medicare beneficiaries to understand what Medicare covers regarding chemotherapy treatments. Fortunately, Medicare covers most chemotherapy treatments and services.

Does Medicare cover chemotherapy?

Chemotherapy is a type of cancer treatment that’s used to damage and destroy cancer cells, preventing them from multiplying. Medicare does cover chemotherapy. So, which parts of Medicare cover chemo treatments?

  • Medicare Part A (hospital insurance) covers chemotherapy treatments given in an inpatient setting. 
  • Medicare Part B (outpatient insurance) covers chemotherapy and radiation treatments given in an outpatient setting. Although chemotherapy is often administered in a hospital or clinic setting, it generally falls under Medicare Part B. Additionally, Medicare Part B covers preventive cancer screenings.
  • Medicare Advantage prescription drug plans (Part C) or stand-alone Medicare Part D plans will help cover the costs of chemotherapy prescriptions that you pick up at the pharmacy.

What’s covered
Does Medicare Part B cover chemotherapy drugs? Does Medicare Part D cover chemotherapy drugs?
Infusion drugs Drugs used at home are covered as Durable Medical Equipment.  Drugs given through an external infusion pump that are not covered by Part A or B may be covered. 
Injectable drugs Injectable drugs are covered and are administered by your healthcare provider. Injectable drugs that can be purchased in pharmacies may be covered. 
Oral anti-cancer drugs Oral anti-cancer drugs are covered by Medicare and you or your healthcare provider can administer the drug.  If the drug is used to treat a condition other than cancer, it may be covered by Part D. 
Oral anti-nausea drugs Oral anti-nausea drugs are covered if administered within 48 hours of cancer treatment.  Oral anti-nausea drugs used for conditions other than cancer or administered more than 48 hours after cancer treatment may be covered.

What’s not covered

Most chemotherapy treatments and services are covered by Medicare. The only time Medicare may deny a claim is if the treatment or service is excluded from consolidated billing. In this scenario, the provider would just need to bill Medicare separately to be reimbursed.

Consolidated billing exclusions

Consolidated billing was established by the Centers for Medicare & Medicare Services (CMS) in 1998. It was created to help eliminate duplicate billings for health services rendered to skilled nursing facility residents by multiple providers. 

There’s a list of drugs and services that are excluded from consolidated billing. However, the provider may bill Medicare directly for reimbursement. The below are only excluded if provided outside of a skilled nursing facility:

  • Radiation therapy
  • Certain chemotherapy
  • Chemotherapy administration

Which drugs are on the Medicare chemotherapy exclusion list?

Chemotherapy is one of the four major categories of services excluded from skilled nursing facility consolidated billing. Drugs on the Medicare chemotherapy exclusion list are unclear. Providers would need to check the annual consolidated billing updates provided by CMS to verify what drugs and services can be billed separately to Medicare Part B. 

What if my chemo treatments are denied by Medicare?

If your claim for chemotherapy is denied, there could be a simple explanation, such as a billing code error. The first step would be to contact your provider directly. They may be able to determine what happened and bill Medicare correctly to resolve the issue.If your provider is unable to determine the reason for the denial, then your next step would be to appeal the denial. The appeals process has five levels. Make sure to keep a copy of everything for your personal records.

Does Medicare require prior authorization for chemotherapy?

With Original Medicare, there is no prior authorization needed for chemotherapy. 

With a Medicare Advantage plan, you may need prior authorization. You need to contact your plan directly to find out what guidelines they have set in place. 

How much does chemotherapy cost with Medicare?

Chemotherapy can cost anywhere between $10,000 to $200,000 without health insurance, depending on the type of cancer you have, the stage of the disease, the number of treatments, the duration of treatments, etc. A round of chemotherapy can cost anywhere between $1,000 to $12,000 per month.

Medicare does not cover 100% of the cost of chemotherapy treatments. 

Since most outpatient chemotherapy treatments are covered under Part B, you’ll be responsible for paying 20% coinsurance for all services and treatments. You’ll also be responsible for the annual Part B deductible, which in 2024 is $240.

If you have a Medigap plan, the 20% coinsurance will be billed directly to your Medigap (Medicare supplement insurance) carrier and covered. Depending on what letter plan you have, you may even get the annual Part B deductible covered. 

Due to the high out-of-pocket costs of chemotherapy, you may consider enrolling in a Medigap plan to protect your finances since traditional Medicare does not have a maximum out-of-pocket limit. 

For those who cannot afford a Medigap plan or get one due to pre-existing conditions, a Medicare Advantage plan (Part C) might be a useful option.

It’s nearly impossible to predict your copayments with a Medicare Advantage plan, except for knowing your maximum out-of-pocket limit. In 2024, the maximum out-of-pocket for Medicare Advantage plans is $8,850, but plans may set lower limits. The MOOP resets annually, which means you could pay the limit twice within 12 months. 

Chronic Condition Special Needs Plans are also offered through some Medicare Advantage carriers. These are limited to beneficiaries with specific chronic conditions, including some cancers. Plans are tailored for these specific conditions to best meet the needs of the beneficiary. 

Other ways to save on chemotherapy

1. Medicare Extra Help

The Extra Help program provides financial assistance so people who meet low-income requirements or are dual-eligible for both Medicaid and Medicare can get discounts on their prescriptions and drug premiums.

2. SingleCare coupons

There are thousands of free coupons available through SingleCare. These coupons can save you money, even if you currently have Medicare or another type of health insurance. You must choose to use SingleCare or Medicare—you can’t use both on the same prescription. There are some instances where you can save more money by using SingleCare instead of your Medicare prescription drug coverage plan. Some common chemotherapy drugs that SingleCare provides discount coupons for include:

3. Medicaid

Medicaid is a health insurance program for low-income people of any age. Medicaid may cover or subsidize goods and services at a higher rate than Medicare. Medicaid eligibility and coverage is determined by the state

RELATED: Medicare vs. Medicaid 

4. Patient assistance programs

Nonprofit organizations and drug manufacturers offer patient assistance programs to eligible cancer patients. Contact programs such as the CancerCare Co-Payment Assistance Foundation, The Leukemia & Lymphoma Society’s Co-Pay Assistance Program, and the HealthWell Foundation for more information.

5. Cancer organizations

There are many cancer organizations that provide financial assistance. Here are some examples:

6. 211

211 is a non-emergency service that you can call to find services (including financial needs and health resources) in your community, state, or country. This free service is available 24/7.

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