Does Medicare Cover Cologuard?

Is the cologuard covered?

A physician will perform the colonoscopy medical procedure in order to examine for any issues within the colon and rectum.

It is typically performed to identify any swollen tissues, ulcers, cancerous tissues, or polyps that may be occurring in the colon and rectum. 

The procedure is very invasive and does require the patient to be placed under anesthesia and sedated. For those who are eligible, they will be required to take a Cologuard test.

Cologuard is the medication that works as an alternative to having a colonoscopy. It aids with the detection of colorectal cancer. 

One of the most frequently asked questions in regards to this kit is whether or not it’s covered by Medicare. We’re going to take a closer look at whether this is the case as well as more about the medication itself. 

By the end of this article you will know everything that you need to know about Cologuard and its coverage by Medicare. 

What are the Medicare Coverage Options for Cologuard?

Medicare does in fact cover Cologuard kits as well as colorectal cancer screenings under certain circumstances.

Cologuard is essentially a DNA stool test kit and is covered by Medicare once every three years. 

This coverage is only applicable to patients with Medicare who are between 50 and 85 years old who do not already have symptoms or are not at risk of developing colorectal cancer. 

You will find that the majority of Medicare plans will let patients get these tests without needing to pay coinsurance, copayments, or deductibles.

It’s important to bear in mind that Cologuard needs to be prescribed through your doctor before it can be covered by Medicare. 

What is Cologuard? 

Cologuard is a kit that can detect signs of colorectal cancer through the evaluation of a sample of the individual’s fecal matter.

Anyone over the age of 50 that is at risk of receiving a colorectal cancer diagnosis is able to use this kit. 

In order to use the kit you must be clear of any signs and symptoms of this type of cancer. You must also have a clear family history of the diagnosis. 

Unlike colonoscopies, Cologuard is not invasive and only requires a solid stool sample to work.

Once the fecal matter has been collected, evaluation of the DNA will then start to see whether there are any specific DNA or blood mutations present within the sample. 

There are certain markers that are able to determine whether any polyps have formed within the digestive system.

We must note that anyone who is at high risk for developing this type of cancer will not be able to use Cologuard. 

Someone with a high risk may be determined by the fact that they are showing symptoms or that they have a family history of the diagnosis.

You may also find that you are at high risk if you have already received a diagnosis for inflammatory bowel disease or adenomatous polyps. 

A Cologuard test was not designed with the intention to replace the colonoscopy. If there are any indications of a digestive tract that is in poor health, then it should be immediately followed up with a colonoscopy. 

Other Options for Colorectal Cancer Screenings

It is true that Cologuard is in fact covered by Medicare when the patient meets all of the criteria. However, it is not the only available option when it comes to screening for colorectal cancer. Other options available include:

Colonoscopy – If you are an individual that is at high risk of developing colorectal cancer, then you are able to get a colonoscopy that is covered by Medicare every 24 months. 

Fecal occult blood test – If you are over the age of 50 you are able to receive this test every 12 months. 

Barium enema – If you are over the age of 50 then you can receive this test every 48 months. If you are at high risk of developing colorectal cancer, then you can get this test covered every 24 months. 

It is important to consult your doctor about the exact cost of these tests with Medicare coverage. 

What is the Cost of Cologuard with Medicare? 

It all depends on the type of insurance that you have in order to determine what the exact price would be. For some providers it will be higher than others. It is important to speak to your doctor about any exact costs. 

A Cologuard test can range between $400-$600. You are able to request laboratory test fees to be covered if you get in touch with your insurance provider. It’s better to ask than not to. 

Over 92% of patients have found themselves with a $0 out of pocket testing cost.

Eligible patients who are between the ages of 5 and 75 who only have an average risk of colorectal cancer should be able to have the costs covered by most insurance providers. 

Is Cologuard Covered by Medicaid? 

Cologuard creators’ laboratories must have a Medicaid provider within your state before they submit your claim. You will find that not all creators are on a Medicaid contract.

Cologuard is continuously adding new states to their plans all the time, so it’s best not to worry too much. Make sure to keep checking with your Medicaid provider.

If you’re thinking about canceling your Cologuard test, then make sure you get in touch with Customer Care first. 

By getting in touch with the Customer Care Center first, you will be able to request additional information. This can be pertaining to the financial assistance you are able to receive.

Some members have even qualified for a 100% discount! 

Conclusion

In most cases, as long as you meet the eligibility criteria, Cologuard will be covered by Medicare. However, it is always best to call and check with your healthcare provider before ordering a prescription. 

We hope that this article has helped to answer any questions you may have about Medicare Cologuard coverage.

Frequently Asked Questions