Most Medicare Advantage plans cover chemotherapy, but the cost you pay depends on which plan you choose and whether your oncologist is in the plan's network

Medicare Advantage plans (also called Part C) must cover all the services that Original Medicare covers, which includes chemotherapy drugs and the visits where you receive them. However, Medicare Advantage plans add their own rules on top of that coverage: they set copays, coinsurance amounts, deductibles, and they require you to use doctors and hospitals in their network. A chemotherapy drug that costs nothing under Original Medicare might cost you $50 per infusion under one plan and $200 under another.

The real question is not whether chemotherapy is covered, but what you will pay out of pocket and whether your cancer center participates in the plan. Before you enroll in a Medicare Advantage plan, or if you are already enrolled and facing a cancer diagnosis, you need to check three things: the plan's drug formulary (its list of covered drugs), the copay or coinsurance for chemotherapy visits, and whether your oncologist's practice is in-network.

Key Takeaways

  • All Medicare Advantage plans must cover chemotherapy because Original Medicare covers it, but each plan sets its own copay, coinsurance, and deductible amounts.
  • Chemotherapy drugs are covered under the plan's pharmacy benefit (Part D), and some plans charge per-infusion copays while others use coinsurance based on the drug's cost.
  • Using an out-of-network oncologist or cancer center typically costs much more under Medicare Advantage than using an in-network provider, sometimes thousands of dollars more per treatment.
  • You can switch to Original Medicare during a cancer diagnosis under a special circumstance called a may have access to life event, though timing and important date matter.
  • The plan's formulary can change each year, so a drug your oncologist prescribed last year may require prior authorization or a higher copay this year.

How chemotherapy costs work under Medicare Advantage

Medicare Advantage plans cover chemotherapy in two parts: the office visit or infusion center visit, and the drug itself. The office visit is usually covered under the plan's medical benefits with a copay (a flat fee like $40) or coinsurance (a percentage of the cost, like 20%). The drug is covered under the pharmacy benefit, which works differently depending on whether the chemotherapy is given by injection or infusion in a doctor's office, or whether you take it as a pill at home.

If your oncologist gives you chemotherapy by infusion in their office or a hospital outpatient center, the drug is typically billed as part of the medical visit, not the pharmacy. In that case, you pay the copay or coinsurance for the visit itself. If you take chemotherapy as a pill at home, it goes through the pharmacy benefit, and you pay based on which tier the drug is on — usually tier 3 or tier 4, which are the highest tiers and carry the largest copays. Tier 4 copays can range from $100 to $500 per month depending on the plan, and some plans use coinsurance instead, meaning you pay a percentage of the drug's cost.

Many Medicare Advantage plans have an out-of-pocket maximum, which is a yearly cap on what you pay for covered services. Once you reach that maximum, the plan pays 100% of covered costs for the rest of the year. In 2024, the out-of-pocket maximum for Medicare Advantage plans is capped at $7,550 for in-network services, though plans can set it lower. If your chemotherapy costs are high, you may hit that maximum partway through treatment.

Checking whether your oncologist and cancer center are in-network

Before you enroll in a Medicare Advantage plan, search the plan's provider directory for your oncologist by name and the cancer center where you receive treatment. Do not assume that because a large hospital system is in-network, all of its doctors are. Many cancer centers contract with Medicare Advantage plans, but individual oncologists within those centers may not, or they may be in-network for some plans but not others.

If your oncologist is out-of-network, you will pay much more. Under Medicare Advantage, out-of-network providers can bill you for the difference between what they charge and what the plan pays — a practice called balance billing. You might pay 40% coinsurance instead of 20%, or a $200 copay instead of $50. Over the course of chemotherapy, which often involves multiple infusions over months, this adds up quickly.

If you are already enrolled in a Medicare Advantage plan and your oncologist is out-of-network, you have options. You can ask your oncologist whether they will accept the plan's payment as full payment (many will, especially for cancer treatment). You can switch to Original Medicare if you are within the annual enrollment period (October 15 to December 7) or if you have a may have access to life event, which includes a cancer diagnosis in some cases. You can also ask the plan whether it will make an exception and cover your out-of-network oncologist, though this is not may provide.

Understanding the drug formulary and prior authorization

Each Medicare Advantage plan publishes a formulary — a list of drugs it covers and the copay or coinsurance for each. Chemotherapy drugs appear on the formulary, but not all of them, and not always at the same tier. Your oncologist may prescribe a drug that is not on the formulary, or that requires prior authorization (a step where the plan reviews the prescription before approving it) or step therapy (a requirement to try a cheaper drug first).

Prior authorization for chemotherapy can delay treatment by days or weeks while the plan's medical reviewers examine your diagnosis and your oncologist's notes. Some plans approve it quickly; others request additional information. Your oncologist's office usually handles the prior authorization request, but you should ask them how long it typically takes and whether there is a backup drug on the formulary in case the first choice is denied.

Formularies change every January 1st. A chemotherapy drug you took last year at a $50 copay might move to a higher tier this year at $150, or it might be removed from the formulary entirely. If you are in the middle of treatment when this happens, the plan may allow you to continue the old copay through the end of your current prescription, but you should confirm this with your plan and your oncologist.

Comparing Medicare Advantage plans if you are shopping for coverage

If you are not yet enrolled in a Medicare Advantage plan and you know you have cancer or are at high risk, use the Medicare Plan Finder tool on Medicare.gov to compare plans in your area. Filter by your oncologist's name and the cancer center you plan to use to see which plans include them in-network. Then compare the copay for the office visit, the tier and copay for your specific chemotherapy drug, and the out-of-pocket maximum.

Write down the details for at least three plans: the copay for an oncology office visit, the copay or coinsurance for your chemotherapy drug, whether prior authorization is required, and the out-of-pocket maximum. Then estimate your total cost by multiplying the office visit copay by the number of visits you expect (your oncologist can tell you this), and the drug copay by the number of months of treatment. This rough estimate will show you which plan costs least for your specific situation.

If you are comparing plans and your oncologist is in-network for all of them, the drug formulary becomes the deciding factor. Call the plans directly and ask whether your specific chemotherapy drug is on the formulary and what tier it is on. Do not rely on the online tool alone — formularies are complex and the tool sometimes shows outdated information.

Switching to Original Medicare during cancer treatment

If you are enrolled in a Medicare Advantage plan and you are diagnosed with cancer, you may be able to switch to Original Medicare outside the normal enrollment period. This is called a may have access to life event. A cancer diagnosis itself does not automatically trigger this, but certain circumstances related to cancer treatment do: if your oncologist is not in-network and the plan will not make an exception, or if the plan denies coverage for a chemotherapy drug your oncologist prescribed, you may have grounds to request a special enrollment period.

To request a special enrollment period, contact Medicare at 1-800-MEDICARE and explain your situation. You will need documentation from your oncologist or the plan's denial letter. If Medicare approves your request, you can switch to Original Medicare, and the switch takes effect on the first day of the following month. Once you are on Original Medicare, you can enroll in a standalone Part D prescription drug plan to cover your chemotherapy drugs.

The downside of switching to Original Medicare mid-year is that you lose any out-of-pocket maximum you had already paid toward under your Medicare Advantage plan. You start fresh on Original Medicare, which means you pay the Part B deductible ($240 in 2024) and then 20% coinsurance for chemotherapy visits and drugs. However, if your Medicare Advantage plan was denying coverage or charging very high copays, Original Medicare may cost less overall.

What happens to your Medicare Advantage plan during long-term chemotherapy

Chemotherapy often lasts several months, and sometimes spans two calendar years. If your treatment crosses from one year into the next, your copays and coinsurance may change on January 1st when the plan's formulary updates. Your out-of-pocket maximum also resets on January 1st, meaning any copays you paid in December do not count toward next year's maximum.

If you are mid-treatment on January 1st, ask your oncologist and your plan whether you can continue your current drug at the old copay through the end of your current prescription, or whether you will pay the new copay when ready. Some plans allow a grace period; others do not. Also confirm that your oncologist remains in-network for the new year — occasionally a provider's contract with a plan ends on December 31st and is not renewed.

Frequently Asked Questions

Does Medicare Advantage cover all chemotherapy drugs?

Medicare Advantage plans must cover chemotherapy because Original Medicare does, but each plan's formulary lists which specific drugs it covers and at what copay. Your oncologist's drug choice may require prior authorization or may not be on the formulary at all. If that happens, your oncologist can request an exception or prescribe an alternative drug that is covered.

What if my oncologist is out-of-network?

You will pay more — often 40% coinsurance instead of 20%, or higher copays. Ask your oncologist whether they will accept the plan's payment as full payment, which many do for cancer care. If not, you can request a special enrollment period to switch to Original Medicare, or ask the plan to make an exception for your care.

Will my copay stay the same if my treatment goes into next year?

No. Copays and formularies change on January 1st. A drug you paid $50 for in December may cost $150 in January. Ask your plan and oncologist in advance what the new copay will be and whether you can finish your current prescription at the old rate.

What is the out-of-pocket maximum and how does it help with chemotherapy costs?

The out-of-pocket maximum is the most you will pay in copays and coinsurance in one year. Once you reach it, the plan pays 100% of covered costs for the rest of that year. In 2024, the maximum is capped at $7,550 for in-network services. If your chemotherapy is expensive, you may hit this maximum partway through treatment.

Can I switch plans if I am unhappy with my coverage during chemotherapy?

During the normal enrollment period (October 15 to December 7), you can switch to any plan. If you are outside that window, you can request a special enrollment period if your current plan is denying coverage or your oncologist is not in-network. Contact Medicare at 1-800-MEDICARE with documentation of your situation.