Medicare Advantage plans cover cancer treatment, but the scope and your out-of-pocket costs depend on which plan you choose and which provider you use

Medicare Advantage (Part C) plans must cover all the same cancer treatments that Original Medicare covers — chemotherapy, radiation, surgery, and hospital stays. However, Medicare Advantage plans add their own rules on top of that coverage. They may require you to use doctors and hospitals within their network, get approval before treatment starts, or pay higher copays for certain drugs. Some plans cover newer cancer drugs that Original Medicare does not. The real question is not whether your plan covers cancer treatment, but what you will pay and which oncologists you can see.

Key Takeaways

  • All Medicare Advantage plans must cover the same basic cancer treatments as Original Medicare, including chemotherapy, radiation, and surgery.
  • Most Medicare Advantage plans require you to use in-network oncologists and hospitals, and may deny coverage if you go out of network without permission.
  • Your plan may require prior authorization — written approval from the insurance company — before your oncologist can start certain treatments.
  • Cancer drugs covered by your plan depend on its formulary, which is the list of covered medications; some plans cover newer drugs that others do not.
  • You should contact your plan directly before starting cancer treatment to learn your copays, deductible, and whether your oncologist is in network.

How Medicare Advantage plans structure cancer coverage

Medicare Advantage plans are required by federal law to cover everything Original Medicare covers for cancer. That means hospital stays, doctor visits, chemotherapy, radiation therapy, and surgery are all included. But Medicare Advantage plans operate differently from Original Medicare. Instead of paying any doctor or hospital that accepts Medicare, you choose a plan run by a private insurance company — UnitedHealthcare, Humana, Anthem, Aetna, or others — and that company decides which providers you can use and what you pay.

Most Medicare Advantage plans are HMO (Health Maintenance Organization) or PPO (Preferred Provider Organization) plans. HMO plans require you to use doctors and hospitals in their network and usually require a referral from your primary care doctor before you see a specialist. PPO plans let you see out-of-network doctors, but you pay more. If you have cancer and your oncologist is not in your plan's network, an HMO plan may not cover their care at all, or may cover it only in emergencies. A PPO plan will cover out-of-network care, but you will pay a higher copay or coinsurance.

Before you start cancer treatment, call your Medicare Advantage plan and ask: Is my oncologist in network? What is my copay for chemotherapy? Do I have a deductible? Does the plan cover the specific drugs my oncologist wants to use? These answers will tell you what your treatment will actually cost.

Prior authorization and treatment approval delays

Many Medicare Advantage plans require prior authorization before your oncologist can start certain cancer treatments. Prior authorization means your doctor must contact the insurance company, describe your diagnosis and the treatment plan, and get written approval before the treatment begins. The insurance company reviews the request to make sure the treatment is medically necessary and follows the plan's guidelines.

Prior authorization can delay treatment by days or weeks. Your oncologist's office usually handles the paperwork, but if the plan denies the request, your doctor may need to appeal or propose a different treatment. Some plans approve certain drugs automatically for cancer patients, while others require authorization for every chemotherapy regimen. Ask your oncologist's office whether your plan requires prior authorization for your specific treatment, and if so, how long approval usually takes. If delays are a concern, you can also ask whether your plan has an expedited review process for urgent cancer cases.

Original Medicare does not require prior authorization for most cancer treatments, which is one reason some people with cancer choose to stay on Original Medicare rather than switch to a Medicare Advantage plan.

Cancer drug coverage and formularies

Each Medicare Advantage plan maintains a formulary — a list of prescription drugs the plan covers. Cancer drugs on the formulary are covered; drugs not on the list are usually not covered, unless your doctor appeals and the plan makes an exception. Formularies vary widely between plans. One plan may cover a newer immunotherapy drug while another does not. One plan may cover a brand-name chemotherapy drug; another may cover only the generic version.

If your oncologist prescribes a drug that is not on your plan's formulary, several things can happen. Your doctor can request a formulary exception, asking the plan to cover the drug anyway. The plan may approve the exception if the drug is medically necessary and you have tried other covered drugs first. The plan may deny the exception, in which case you can appeal or pay for the drug out of pocket. Some cancer drugs cost thousands of dollars per month, so formulary coverage matters enormously.

Before you start treatment, ask your oncologist to check your plan's formulary for the drugs they plan to use. Most plans post their formularies online, or you can call the plan and ask. If a drug you need is not covered, ask your doctor whether there is a covered alternative, or whether they can request an exception.

Out-of-pocket costs for cancer treatment

Medicare Advantage plans have annual out-of-pocket maximums — a cap on how much you pay in copays and coinsurance in a year. Once you reach that maximum, the plan pays 100 percent of covered services for the rest of the year. Out-of-pocket maximums vary by plan and by year, but they are usually between $5,000 and $10,000. However, this maximum applies only to in-network care. If you use an out-of-network provider, you may pay more, and the out-of-pocket maximum may not explore the same way.

Cancer treatment often involves multiple visits, imaging scans, lab work, and medications, so you may reach your out-of-pocket maximum quickly. Your copays might be $50 per chemotherapy session, $200 per radiation treatment, or a percentage of the drug cost. Some plans charge a flat copay for all chemotherapy; others charge based on the specific drug. Call your plan and ask for an estimate of your costs for the specific treatment your oncologist recommends.

If cost is a concern, you can also ask your oncologist's office about patient information programs run by drug manufacturers. Many companies that make cancer drugs offer free or reduced-cost medications to people who cannot afford them, regardless of insurance.

Switching plans or returning to Original Medicare

If you are already on a Medicare Advantage plan and are diagnosed with cancer, you have options. You can stay on your current plan if it covers your treatment and your oncologist is in network. You can switch to a different Medicare Advantage plan during the annual enrollment period (October 15 to December 7 each year) if you want better cancer drug coverage or a plan that includes your preferred oncologist. You can also switch to Original Medicare, though you can do this only during the annual enrollment period or if you have a may have access to life event — and a cancer diagnosis may may have access to, depending on your plan.

If you switch to Original Medicare after a cancer diagnosis, you should also enroll in a Medigap supplemental plan if you can afford it. Medigap covers some of the copays and coinsurance that Original Medicare does not, which can reduce your out-of-pocket costs significantly during cancer treatment.

Talk to your plan or to Medicare directly (1-800-MEDICARE) about your options. If you are having trouble affording treatment, your oncologist's office may also have a social worker who can help you understand your coverage and find financial resources.

Frequently Asked Questions

Can my Medicare Advantage plan refuse to cover cancer treatment?

No, your plan must cover all cancer treatments that Original Medicare covers. However, your plan can require you to use in-network providers, get prior authorization, or use a covered drug instead of the one your doctor first recommended. If your plan denies a specific treatment, your doctor can appeal the decision.

What happens if my oncologist is out of network?

If you have an HMO plan, out-of-network care is usually not covered except in emergencies. If you have a PPO plan, out-of-network care is covered but you pay a higher copay or coinsurance. Before starting treatment, confirm whether your oncologist is in your plan's network, and if not, ask whether your plan will cover out-of-network cancer care.

Do I have to pay for cancer drugs that are not on my plan's formulary?

Not necessarily. Your doctor can request a formulary exception, and the plan may cover the drug if it is medically necessary. If the plan denies the exception, you can appeal or ask about patient information programs from the drug manufacturer.

Can I switch to Original Medicare if I have cancer?

You can switch during the annual enrollment period (October 15 to December 7). A cancer diagnosis may also may have access to as a life-changing event that lets you switch outside the enrollment period — contact Medicare at 1-800-MEDICARE to ask whether you may have access to.

How do I know what my cancer treatment will cost?

Call your Medicare Advantage plan and provide your oncologist's name, the specific treatments planned, and the drugs recommended. Ask for your copay amounts, whether prior authorization is required, and whether all drugs are covered. Your plan should give you a cost estimate before treatment starts.