Since Medicare covers colonoscopies, you might think it also covers all types of colonoscopy prep, but that\u2019s 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\u2019s important to know how much they\u2019ll actually cost. We\u2019ve got all the details on what Medicare Part D might cover, how much patients pay, and how to save money.<\/p>\n
Polyethylene glycol (PEG) is an osmotic laxative that works by pulling water into the intestines,<\/a> which softens the stool and makes bowel movements easier. It\u2019s 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.<\/p>\n 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\u20132 liters instead, which is easier for the patient. MoviPrep and Plenvu<\/a> are two of the most common low-volume PEG-based kits, while some other low-volume (non-PEG-based) options include Clenpiq<\/a>, Sutab<\/a> (oral tablets), and Suprep.<\/p>\n Patients previously had to drink all the medications and required fluids the night before their procedure, but it\u2019s recently become more common to split it up. \u201cI 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,\u201d says Savita Srivastava, MD<\/a>, gastroenterologist and microbiome specialist. \u201cI 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.\u201d<\/p>\n Even though the Affordable Care Act requires coverage for colonoscopy screenings<\/a> 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<\/a>, 83% of Medicare claims for colonoscopy prep kits come with out-of-pocket costs.<\/p>\n 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\u2019s not a guarantee. \u201c 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,\u201d Dr. Srivastava says. \u201cCoverage is almost entirely dependent on the specific insurer’s formulary tiers and whether the patient has met their annual Part D deductible.\u201d<\/p>\n Medicare spent<\/a> 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.<\/p>\n That\u2019s 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.<\/p>\n Medicare Part B, for the most part, is specifically for in-office procedures and treatments<\/a>. In this case, that includes the colonoscopy itself and the required anesthesia. As prescription drugs, colonoscopy preparation kits aren\u2019t administered in the healthcare provider\u2019s office, so Part B won\u2019t cover them.<\/p>\n Medicare Advantage<\/a> (sometimes referred to as \u201cMedicare Part C\u201d) 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\u2019s formulary on Medicare.gov (using the Plan Finder tool<\/a>) to see if your plan will cover PEG prep kits.<\/p>\nDoes Medicare cover low-volume PEG preps?<\/h2>\n
Does Medicare Part D cover low-volume PEG preps?<\/h3>\n
Does Medicare Part B cover colonoscopy prep?<\/h3>\n
Does Medicare Advantage cover low-volume preps?<\/h3>\n
How much do low-volume PEG preps cost with Medicare?<\/h2>\n