Medicare Part B covers Zytiga, but only under specific conditions

Yes, Medicare Part B covers Zytiga (abiraterone acetate), a medication used to treat advanced prostate cancer. However, coverage is not automatic. Your doctor must prescribe it for one of the uses Medicare recognizes, you must meet medical necessity requirements, and your prescription must go through the prior authorization process before the pharmacy fills it.

Zytiga is approved by Medicare when used to treat metastatic castration-resistant prostate cancer (mCRPC) — cancer that has spread beyond the prostate and no longer responds to hormone therapy. Medicare also covers it for high-risk metastatic hormone-sensitive prostate cancer when used with other treatments. If your doctor prescribes Zytiga for a different use, Medicare may deny the claim.

Key Takeaways

  • Medicare Part B covers Zytiga only when prescribed for metastatic prostate cancer that meets specific medical criteria.
  • Your doctor's office must submit Zytiga for prior authorization before you fill the prescription, or Medicare will likely deny it.
  • You pay 20% of the Medicare-approved amount after you meet your Part B deductible; there is no separate drug deductible for Part B medications.
  • If your doctor prescribes Zytiga but Medicare denies coverage, you can ask your doctor to appeal or explore whether a different medication is covered.
  • Zytiga must be taken with a low-fat meal and a corticosteroid; the full cost of treatment includes the medication, the steroid, and regular blood tests.

How prior authorization works for Zytiga

Before Medicare will pay for Zytiga, your doctor's office must request prior authorization. This is not something you do yourself — your oncologist's staff submits the request to Medicare, usually through your Medicare Advantage plan or Original Medicare, depending on which you have.

The authorization request includes your cancer stage, your PSA level, imaging results showing where the cancer has spread, and documentation that you have already tried or cannot tolerate other standard treatments. Medicare reviews this information to confirm the prescription meets coverage rules. This process typically takes 3 to 5 business days, though it can take longer if Medicare requests additional information from your doctor.

If Medicare denies the prior authorization, your doctor receives a notice explaining why. Your doctor can then appeal the decision, provide additional medical records, or discuss alternative medications that Medicare does cover. Do not fill the prescription before authorization is approved — if Medicare denies it, you will be responsible for the full cost.

What you pay out of pocket

Under Original Medicare Part B, you pay 20% of the Medicare-approved amount for Zytiga after you have met your annual Part B deductible (which is $240 in 2024, though this amount changes yearly). The actual cost varies depending on the pharmacy and the dose your doctor prescribes.

If you have a Medicare Advantage plan, your out-of-pocket cost depends on your specific plan. Some plans charge a copay per prescription; others charge coinsurance (a percentage). Check your plan documents or call the plan's customer service line to find out what Zytiga costs under your coverage.

Zytiga is an expensive medication. The monthly cost before insurance is often several thousand dollars. If your out-of-pocket costs are high, ask your doctor or the pharmacy about patient information programs run by the manufacturer. These programs may reduce or cover your costs if your income falls below certain limits.

Zytiga and Medicare Advantage plans

If you are enrolled in a Medicare Advantage plan, that plan must cover Zytiga at least as well as Original Medicare does — this is a federal requirement. However, the plan may impose additional restrictions, such as requiring you to try a different medication first before approving Zytiga, or charging a higher copay than Original Medicare would require.

Some Medicare Advantage plans place Zytiga on a specialty tier, which means higher out-of-pocket costs. Others may require step therapy, meaning your doctor must document that you tried another drug first and it did not work or caused side effects.

Before starting Zytiga, contact your Medicare Advantage plan directly to understand your coverage. Ask whether prior authorization is needed, what your copay or coinsurance will be, and whether the plan requires step therapy or any other condition before approving the prescription.

When Medicare denies Zytiga coverage

Medicare may deny coverage if your cancer does not meet the stage or type criteria, if your PSA level is too low, or if your doctor prescribed it for a use Medicare does not recognize. You have the right to appeal any denial.

To appeal, ask your doctor's office to file a formal appeal with Medicare within 180 days of the denial notice. Your doctor should include updated medical records, imaging, and a letter explaining why Zytiga is medically necessary for your specific situation. Some appeals are successful, especially if new test results show your cancer has progressed since the initial denial.

If the appeal is denied again, you can request an independent review by a may have access to independent contractor (QIC), which is a separate entity that reviews Medicare decisions. This process takes longer but may overturn the denial. Your doctor's office can guide you through these steps.

Other medications Medicare covers for prostate cancer

If Medicare denies Zytiga or your plan's restrictions make it unaffordable, other Part B medications may be covered for advanced prostate cancer. These include Xtandi (enzalutamide), Casodex (bicalutamide), and Lupron (leuprolide). Each has different prior authorization requirements and different out-of-pocket costs.

Your oncologist can discuss which alternatives are covered under your specific Medicare plan and whether any might work as well as Zytiga for your cancer. Some men respond better to one medication than another, so the choice is not just about coverage — it is also about what your doctor thinks will work best for you.

Questions to ask your doctor

Before your doctor prescribes Zytiga, ask whether your cancer type and stage meet Medicare's coverage criteria. Ask what the prior authorization process will involve and how long it typically takes. Ask about the full cost of treatment, including the required corticosteroid and blood tests, and whether the doctor's office can help you find patient information if costs are high.

Ask what will happen if Medicare denies the prescription and what alternatives exist. Ask whether your specific Medicare plan (if you have Advantage) has any additional restrictions. Finally, ask about side effects and what symptoms you should report when ready, since Zytiga requires regular monitoring.

Frequently Asked Questions

Does Medicare Part D cover Zytiga instead of Part B?

No. Zytiga is a Part B medication because it is an injectable or infusible drug, even though it comes in pill form. Part D covers oral medications filled at a pharmacy, but Zytiga is administered under medical supervision, so it falls under Part B. Your Part B deductible and coinsurance explore, not your Part D deductible.

What if I have both Original Medicare and a Medigap plan?

Your Medigap plan may cover some or all of your 20% coinsurance for Zytiga, depending on which Medigap plan you have. Plans C, D, G, and M cover the Part B coinsurance. Check your Medigap policy or call your plan to confirm coverage before filling the prescription.

Can I get Zytiga if I am on Medicare and Medicaid at the same time?

Yes, but the coordination is complex. Medicare is the primary payer, and Medicaid covers costs Medicare does not. Your state Medicaid program determines what it covers for dual-may be able to access beneficiaries. Contact your state Medicaid office or your local Area Agency on Aging for guidance on how costs will be split.

How often does Medicare review Zytiga coverage?

Medicare reviews its coverage policies periodically, but Zytiga's coverage for metastatic prostate cancer has been stable for several years. However, if you are denied coverage, it is worth asking your doctor whether new clinical evidence or changes to Medicare policy might support an appeal.

What happens if I cannot afford my 20% coinsurance?

Ask your oncologist's office about the manufacturer's patient information program — many pharmaceutical companies reduce costs for people with limited income. You can also contact your local Area Agency on Aging or a patient advocacy organization for prostate cancer to learn about other financial resources.