Medicare covers most cancer treatments, but not all of them, and what you pay depends on which part of Medicare you have

Medicare Part A covers inpatient hospital care for cancer treatment, including chemotherapy given during a hospital stay, surgery, and radiation therapy delivered in a hospital setting. Medicare Part B covers outpatient chemotherapy, radiation, and doctor visits at cancer centers and oncology offices. Part D covers some cancer drugs you take by mouth at home. However, Medicare does not cover all cancer drugs — some newer medications are not on the Part D formulary, and coverage rules change. The amount you pay out of pocket depends on your deductible, copayments, and coinsurance under whichever parts you have.

Key Takeaways

  • Medicare Part A covers inpatient cancer treatment including hospital stays, surgery, and chemotherapy given in the hospital.
  • Medicare Part B covers outpatient chemotherapy, radiation therapy, oncology office visits, and imaging scans like CT and PET scans.
  • Part D covers some oral cancer medications, but not all — you need to check your specific plan's formulary to see if your drug is covered.
  • You will owe a deductible, copayments, or coinsurance depending on the type of care and your coverage, and costs can be substantial during active treatment.
  • Some cancer drugs and newer treatments may require prior authorization from Medicare before your doctor can prescribe them.

What Medicare Part A covers for cancer

Part A covers the cost of a hospital stay when you need inpatient treatment for cancer. This includes the room, meals, nursing care, and most medications given to you while you are admitted. If you have chemotherapy as an inpatient — meaning you stay overnight in the hospital to receive it — Part A pays for that chemotherapy and the hospital stay together.

Part A also covers surgery for cancer removal when performed in a hospital. If you need radiation therapy delivered in a hospital's radiation oncology department during an inpatient stay, Part A covers that as well. You pay a deductible for each benefit period (currently $1,676 for 2024, though this amount changes yearly), and then Part A covers the rest of inpatient care for up to 60 days in a benefit period.

What Medicare Part B covers for cancer

Part B covers outpatient cancer treatment, which is most of what happens during active cancer care. This includes chemotherapy given in an oncology office or outpatient cancer center, radiation therapy at a radiation oncology clinic, and all visits to your oncologist and other cancer specialists. Part B also covers imaging scans used to diagnose and monitor cancer, such as CT scans, PET scans, and MRI scans.

Part B covers lab work and pathology tests related to your cancer diagnosis and treatment. It covers bone marrow biopsies, genetic testing for hereditary cancer risk, and monitoring blood counts during chemotherapy. You pay 20 percent coinsurance for most Part B services after you meet your annual deductible (currently $240 for 2024). Some preventive cancer screenings — like mammograms, colorectal cancer screening, and cervical cancer screening — are covered at no cost to you.

What Medicare Part D covers for cancer medications

Part D covers prescription drugs you take by mouth, including some oral cancer medications. However, not every cancer drug is on every Part D plan's formulary, and some plans may require prior authorization before your doctor can prescribe a drug. You need to check your specific plan's formulary — the list of covered drugs — to see whether your medication is covered.

If your cancer drug is not on your plan's formulary, you have options. You can ask your doctor to request a coverage exception, which the plan may grant if the drug is medically necessary. You can switch to a different Part D plan during the annual open enrollment period (October 15 to December 7 each year) if another plan covers your drug. Some cancer drugs are very expensive, and you may reach the coverage gap (also called the "donut hole") where you pay more out of pocket — but Medicare has limits on how much you pay in a year.

Cancer drugs that may not be covered

Some newer cancer medications, particularly targeted therapies and immunotherapies, are not covered by Part D because they are given by injection or infusion in a doctor's office or hospital rather than taken by mouth. These drugs are typically covered under Part B instead, as part of your outpatient care. Your oncologist's office will bill Part B for the drug and the infusion service together.

Some oral cancer drugs are covered under Part B rather than Part D if they are given as part of a chemotherapy regimen in a medical setting. Ask your oncologist's office which part of Medicare covers your specific drug and whether prior authorization is needed. If a drug is not covered by either Part B or Part D, you can ask your doctor about patient information programs run by the drug manufacturer, which sometimes provide the medication at reduced cost or free.

Prior authorization and coverage decisions

Medicare or your Part D plan may require prior authorization before your doctor prescribes certain cancer drugs. This means your doctor's office must contact Medicare or the plan and get approval before you start the medication. Prior authorization can delay treatment, so ask your oncologist's office to start this process as soon as the drug is prescribed, not after you try to fill it at the pharmacy.

If Medicare or your plan denies coverage for a drug your doctor recommends, you have the right to appeal. Your doctor's office can submit a written appeal explaining why the drug is medically necessary for your specific cancer. This process can take time, so discuss the timeline with your doctor and ask whether there are alternative drugs that are already covered while the appeal is being reviewed.

Out-of-pocket costs during cancer treatment

Cancer treatment can be expensive even with Medicare. You will owe your Part B deductible before coverage begins, then 20 percent coinsurance for most outpatient services. If you receive chemotherapy or radiation therapy in a hospital outpatient department, you may owe a copayment instead of coinsurance — ask the hospital's billing office what you will owe before treatment starts.

If you have a Medigap supplemental insurance policy, it may cover some or all of your deductible and coinsurance, which can significantly reduce your out-of-pocket costs. If you have a Medicare Advantage plan instead of Original Medicare, your costs work differently — you pay copayments or coinsurance set by your plan, and your plan may have a different list of covered cancer drugs. Review your plan documents or call your plan's customer service to understand your specific costs before treatment begins.

Questions to ask your oncologist and Medicare

Before you start cancer treatment, ask your oncologist: "Is this treatment covered by Medicare?" and "Will I need prior authorization?" Ask the oncology office's billing staff what your out-of-pocket cost will be and whether they can submit claims to Medicare on your behalf. If you take oral cancer medications, ask your pharmacy to check your Part D plan's formulary before you fill the prescription.

If you are unsure whether a service is covered, call Medicare directly at 1-800-MEDICARE (1-800-633-4227). You can also visit Medicare.gov and use the "Find Care Providers" tool to check coverage for specific services. If you have a Part D plan, call your plan's customer service number — it is on your insurance card — and ask whether a specific drug is covered and whether prior authorization is needed.

Frequently Asked Questions

Does Medicare cover clinical trials for cancer treatment?

Medicare covers routine care costs for cancer patients enrolled in approved clinical trials, including chemotherapy, radiation, and doctor visits related to the trial. However, Medicare does not cover the cost of the experimental drug itself — that is usually paid by the research sponsor. Ask your oncologist whether the trial is Medicare-approved and what costs you will owe.

What if my cancer drug costs more than my Part D plan's limit?

Part D has an annual out-of-pocket spending limit (currently $7,050 for 2024, though this changes yearly). Once you reach this limit, your plan pays 95 percent of your drug costs for the rest of the year. If your cancer drug is very expensive and you reach this limit quickly, you may may have access to for the Extra Help program, which reduces Part D costs for people with limited income. Call 1-800-MEDICARE to ask about Extra Help.

Does Medicare cover wigs or prosthetics after cancer treatment?

Medicare does not cover wigs or hairpieces. However, Medicare Part B covers breast prostheses (artificial breasts) and bras with prostheses after mastectomy, with a doctor's prescription. Some state Medicaid programs and nonprofit organizations offer wigs at reduced cost — ask your oncology social worker for local resources.

Will I owe more if I get cancer treatment at an out-of-network facility?

If you have Original Medicare (Part A and Part B), there are no out-of-network providers — Medicare is accepted nationwide. If you have a Medicare Advantage plan, you may owe more if you go out of network. Check your plan documents or call your plan to see whether your cancer center is in-network before starting treatment.

Can I switch Medicare plans if my cancer drug is not covered?

You can switch Part D plans during the annual open enrollment period (October 15 to December 7) or if you have a may have access to life event, such as a new cancer diagnosis. You cannot switch Medicare Advantage plans outside of open enrollment unless you have a may have access to event. Ask your doctor's office or call 1-800-MEDICARE to find out whether a new diagnosis qualifies you to switch plans outside the normal enrollment window.