Medicare covers chemotherapy, but what you pay depends on which part of Medicare you have and where you receive treatment.

If you have Original Medicare (Part A and Part B), chemotherapy is covered as a medically necessary cancer treatment. Part B covers chemotherapy drugs given in a doctor's office or hospital outpatient setting. Part A covers chemotherapy if you are admitted to a hospital as an inpatient. If you have a Medicare Advantage plan (Part C), chemotherapy is covered, but you use your plan's network providers and follow your plan's rules about referrals and prior approval.

The amount you pay out of pocket varies. With Original Medicare, you typically pay 20 percent of the approved amount for chemotherapy drugs and related services after you meet your Part B deductible. If you receive chemotherapy in a hospital outpatient department, you may pay a copay or coinsurance. With Medicare Advantage, your costs depend on your specific plan — some charge a copay per visit, others charge coinsurance, and some have an annual out-of-pocket maximum.

Key Takeaways

  • Original Medicare Part B covers chemotherapy given in a doctor's office or outpatient hospital setting; Part A covers inpatient chemotherapy.
  • With Original Medicare, you pay 20 percent coinsurance after meeting your Part B deductible; costs vary by plan with Medicare Advantage.
  • Chemotherapy drugs covered by Medicare must be medically necessary and prescribed by your oncologist as part of a cancer treatment plan.
  • Some chemotherapy drugs may require your doctor to request prior approval from Medicare before treatment begins.
  • Supplemental insurance (Medigap) or a low-income program may help cover your out-of-pocket costs if you have Original Medicare.

How Original Medicare Part B Covers Chemotherapy Drugs

Part B covers chemotherapy drugs administered in a doctor's office, hospital outpatient department, or ambulatory surgery center. This includes intravenous (IV) chemotherapy, oral chemotherapy pills, and injectable chemotherapy. The drug must be prescribed by your oncologist as part of your cancer treatment plan and must be on Medicare's list of covered drugs.

You pay 20 percent of the Medicare-approved amount for the drug and the administration (the cost of giving the drug to you) after you meet your annual Part B deductible. The deductible amount varies year to year. If your chemotherapy is given in a hospital outpatient department, you may pay a different amount — sometimes a copay instead of coinsurance — because hospital outpatient departments bill differently than doctor's offices.

If your chemotherapy costs $5,000 and the Medicare-approved amount is $4,000, you would pay 20 percent of $4,000 ($800) after your deductible is met. The remaining $3,200 is paid by Medicare.

How Original Medicare Part A Covers Inpatient Chemotherapy

If you are admitted to a hospital as an inpatient and receive chemotherapy during your stay, Part A covers it as part of your hospital care. You pay a copay for each day of your hospital stay, up to a maximum number of days. This copay amount changes each year.

Inpatient chemotherapy is less common than outpatient chemotherapy. Most people receive chemotherapy in an outpatient setting because it is safer and allows you to recover at home. You would be admitted as an inpatient only if your condition requires close monitoring or if you are receiving a stem cell transplant as part of your cancer treatment.

Medicare Advantage Coverage of Chemotherapy

Medicare Advantage plans must cover chemotherapy because it is a medically necessary treatment. However, each plan sets its own rules about how much you pay and which doctors and facilities you can use. Most Medicare Advantage plans require you to use doctors and hospitals in their network, and some require a referral from your primary care doctor before you see an oncologist.

Your out-of-pocket cost depends on your specific plan. Some plans charge a copay per chemotherapy visit (for example, $50 per visit), while others charge coinsurance (a percentage of the cost). Many plans have an annual out-of-pocket maximum — once you reach this amount, the plan pays 100 percent of covered services for the rest of the year.

Before you start chemotherapy, contact your Medicare Advantage plan to find out whether your oncologist is in the network, whether you need a referral, and what your copay or coinsurance will be. Some plans require prior approval before chemotherapy begins.

Prior Approval and Restrictions on Chemotherapy Drugs

Some chemotherapy drugs require prior approval from Medicare before your doctor can prescribe them. This means your oncologist must submit information about your cancer diagnosis and treatment plan to Medicare (or to your Medicare Advantage plan) and receive approval before the drug is given to you. Prior approval can take a few days to a week.

Prior approval exists to make sure the drug is medically necessary for your specific type of cancer and stage. It is not a denial of coverage — it is a check to confirm the drug is appropriate for you. If Medicare denies prior approval, your doctor can appeal the decision or discuss alternative chemotherapy drugs with you.

Your doctor's office usually handles the prior approval request. Ask your oncologist's staff whether your chemotherapy drug needs prior approval and how long it typically takes.

Oral Chemotherapy Pills and Medicare Coverage

Oral chemotherapy pills are covered by Medicare Part B, but the coverage rules are different from IV chemotherapy. Part B covers oral chemotherapy drugs that are used to treat cancer, but you must have a prescription from your oncologist and the drug must be on Medicare's list of covered drugs.

You pay 20 percent coinsurance after your Part B deductible, just as you would for IV chemotherapy. However, oral chemotherapy is sometimes covered under Part D (prescription drug coverage) instead of Part B, depending on the specific drug and how it is classified. Ask your doctor or pharmacist whether your oral chemotherapy is covered under Part B or Part D, because this affects your out-of-pocket cost.

If your oral chemotherapy is covered under Part D, you pay whatever your Part D plan charges for that drug — this could be a copay, coinsurance, or a percentage of the cost, depending on your plan.

Managing Out-of-Pocket Costs for Chemotherapy

Chemotherapy can be expensive, and your out-of-pocket costs can add up quickly. If you have Original Medicare, a Medigap policy (supplemental insurance) can help pay your coinsurance and deductible. Medigap policies are sold by private insurance companies and cover costs that Original Medicare does not pay.

If your income is low, you may be may be able to access for a Medicare Savings Program run by your state. These programs help pay your Medicare premiums, deductibles, and coinsurance. You can contact your state Medicaid office or call 1-800-MEDICARE to learn whether you may have access to.

Some drug manufacturers offer patient information programs that provide chemotherapy drugs at reduced cost or for free if you meet income requirements. Ask your oncologist's office whether your chemotherapy drug has a patient information program.

If you have a Medicare Advantage plan and your out-of-pocket costs are high, you can switch to Original Medicare during the annual open enrollment period (October 15 to December 7 each year) and add a Medigap policy.

Frequently Asked Questions

Does Medicare cover chemotherapy for all types of cancer?

Yes, Medicare covers chemotherapy for all types of cancer if it is medically necessary and prescribed by your doctor. The specific chemotherapy drug must be approved by the FDA and on Medicare's list of covered drugs. Your doctor determines which chemotherapy is appropriate for your cancer type and stage.

What if my chemotherapy drug is not on Medicare's covered list?

If your oncologist prescribes a chemotherapy drug that is not on Medicare's covered list, you can ask your doctor to request an exception. Medicare may cover the drug if your doctor provides medical evidence that it is necessary for your specific cancer. This process is called an appeal or exception request and can take one to two weeks.

Do I have to pay for chemotherapy if I have both Medicare and Medicaid?

If you have both Medicare and Medicaid (called "dual may be able to access"), Medicaid may help pay your Medicare copays, coinsurance, and deductibles. Contact your state Medicaid office to learn what information you may have access to for. Your out-of-pocket cost may be zero or very low.

Can I get chemotherapy from any oncologist, or does it have to be in-network?

With Original Medicare, you can see any oncologist who accepts Medicare, whether in-network or out-of-network. With Medicare Advantage, you must use an in-network oncologist unless your plan allows out-of-network care. Check your plan documents or call your plan to confirm which oncologists are in your network.

Will Medicare pay for chemotherapy side effect medications?

Yes, Medicare covers medications prescribed to manage chemotherapy side effects, such as nausea, pain, or low blood cell counts. These medications are covered under Part B if given in a doctor's office or hospital, or under Part D if you take them at home as pills. You pay your normal coinsurance or copay for these medications.