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

Medicare Part B covers chemotherapy drugs and infusion services when you receive them in a hospital outpatient department or a doctor's office. Medicare Part D covers chemotherapy pills you take at home. If you have chemotherapy as an inpatient in a hospital, Medicare Part A covers the full cost of the hospital stay, including the drugs given during that stay. The catch is that you will owe a deductible, and you may owe coinsurance or copayments depending on your situation and which part of Medicare is paying.

The coverage rules differ based on where the chemotherapy happens and how it is given. Understanding which part of Medicare pays for your specific treatment helps you know what to expect at the pharmacy or billing desk.

Key Takeaways

  • Medicare Part B covers chemotherapy infusions in a hospital outpatient setting or doctor's office, and you pay 20 percent coinsurance after you meet your Part B deductible.
  • Medicare Part D covers chemotherapy pills taken at home, with your copayment or coinsurance depending on which tier the drug falls on in your plan's formulary.
  • Medicare Part A covers chemotherapy given during a hospital inpatient stay as part of the overall hospital bill, subject to your Part A deductible and copayments.
  • Some chemotherapy drugs are covered under Part B as "Part B drugs" even though they are pills, so you should confirm with your doctor or pharmacist which part covers your specific medication.
  • Your out-of-pocket costs vary widely based on your deductible, coinsurance rate, and whether you have supplemental coverage or a Medicare Advantage plan.

Chemotherapy covered under Medicare Part B

When you receive chemotherapy as an outpatient — meaning you go to a hospital or doctor's office and return home the same day — Medicare Part B covers the drug itself and the cost of administering it. This includes the nurse time, the IV supplies, and the facility where the infusion takes place. You pay 20 percent coinsurance after you meet your annual Part B deductible, which is $240 in 2024. This means if your chemotherapy infusion costs $5,000, you would owe $1,000 in coinsurance (20 percent of $5,000) once your deductible is met.

Part B covers most chemotherapy drugs given by injection or infusion, including common ones like Herceptin, Avastin, and Rituxan. The drug must be one that Medicare has determined is reasonable and necessary for your diagnosis. Your oncologist's office will know whether a specific drug is covered under Part B, and they can tell you your expected out-of-pocket cost before treatment begins.

Chemotherapy pills covered under Medicare Part D

Chemotherapy pills you take at home are covered under Medicare Part D, your prescription drug plan. Your copayment or coinsurance depends on which tier the drug falls on in your plan's formulary — the list of covered drugs. Tier 1 drugs (generic) usually have the lowest copayment, while specialty tier drugs (which include many newer chemotherapy pills) can have much higher copayments, sometimes $100 to $300 per month or more.

Some chemotherapy pills are expensive, and your plan may require prior authorization before the pharmacy will fill the prescription. This means your doctor has to submit paperwork to your Part D plan asking permission to cover the drug. The approval process usually takes a few business days, but can sometimes take longer. If your plan denies coverage, your doctor can appeal or ask the plan to make an exception.

If you do not have a Part D plan, you can enroll during the annual enrollment period (October 15 to December 7 each year) or within 63 days of losing other drug coverage. If you miss this window, you may owe a late enrollment penalty on top of your premiums.

Chemotherapy during a hospital inpatient stay

If you are admitted to the hospital and receive chemotherapy while you are an inpatient, Medicare Part A covers the chemotherapy drug as part of your hospital bill. You do not pay separately for the drug — it is included in your hospital copayment. For 2024, you owe a $1,632 deductible for the first 60 days of a hospital stay, then $408 per day for days 61 to 90, and $816 per day for days 91 to 150. After 150 days, you owe the full cost.

Most people do not stay in the hospital for the entire course of chemotherapy. Inpatient chemotherapy usually happens when you are admitted for a complication, a stem cell transplant, or an intensive treatment protocol that requires close monitoring. Once you are discharged, any follow-up chemotherapy will be covered under Part B (if given in an outpatient setting) or Part D (if it is a pill you take at home).

Medicare Advantage plans and chemotherapy coverage

If you have a Medicare Advantage plan (Part C), your coverage for chemotherapy works differently than Original Medicare. Medicare Advantage plans must cover at least as much as Original Medicare, but they set their own rules about copayments, coinsurance, and which drugs are covered. Some plans have lower copayments for chemotherapy than Original Medicare, while others have higher ones.

Most Medicare Advantage plans require you to use doctors and hospitals in their network. If you go out of network for chemotherapy, you may owe much more or the plan may not cover it at all. Before starting chemotherapy, call your Medicare Advantage plan to confirm that your oncologist and the treatment facility are in network, and ask what your copayment will be.

Medicare Advantage plans also often have an out-of-pocket maximum — a yearly limit on what you pay. Once you reach that limit, the plan covers 100 percent of your costs for the rest of the year. Original Medicare does not have an out-of-pocket maximum, so your costs can be higher if you need extensive treatment.

Supplemental insurance and chemotherapy costs

If you have a Medigap (supplemental) policy, it can help pay the coinsurance and deductibles that Original Medicare does not cover. For example, if you owe 20 percent coinsurance for chemotherapy infusions, a Medigap plan can pay some or all of that 20 percent, depending on which Medigap plan you have. Plans C, D, F, and G cover the Part B deductible, so you would not owe that $240 before your coinsurance kicks in.

Medigap plans do not cover chemotherapy pills under Part D — that is a separate benefit. But if you take a chemotherapy pill and owe a copayment under Part D, some Medigap plans will help with that cost as well. Check your Medigap policy documents or call your insurance company to see what it covers.

What to do before starting chemotherapy treatment

Before your first chemotherapy appointment, contact your Medicare plan and ask three things: Is this drug covered? What is my copayment or coinsurance? Do I need prior authorization? Write down the drug name, the dose, and how often you will receive it, because the plan may ask for these details.

If you have Original Medicare with a Part D plan, call both your Part B provider (usually Medicare directly at 1-800-MEDICARE) and your Part D plan. If you have a Medicare Advantage plan, call the plan's customer service number on the back of your card. Ask them to put the answer in writing so you have it for your records.

If the copayment is more than you can afford, ask your oncologist's office about patient information programs run by the drug manufacturer. Many chemotherapy drug makers offer free or reduced-cost medication to people who meet income requirements. Your doctor's office can help you explore.

Frequently Asked Questions

Does Medicare cover the cost of a wig or head covering after chemotherapy?

Medicare does not cover wigs or head coverings as a standard benefit. However, some Medigap plans or Medicare Advantage plans may cover them. You can also check whether your state Medicaid program covers them, or whether a local cancer organization offers free wigs to patients undergoing treatment.

What if my oncologist prescribes a chemotherapy drug that Medicare does not cover?

Your doctor can request an exception from your Medicare plan, asking them to cover a drug that is not on the formulary. This is called a coverage information request. Your doctor's office usually handles this paperwork. If the plan denies the request, your doctor can appeal. The process can take one to two weeks, so ask your doctor to submit the request as soon as possible if you need the drug urgently.

Will I owe more if I get chemotherapy at a cancer center instead of a hospital?

It depends on your plan. If the cancer center is a hospital outpatient department, Medicare Part B covers it the same way. If it is a freestanding cancer center (not part of a hospital), Medicare Part B still covers it, but your copayment may be different. Call your plan before your first appointment to confirm the facility is covered and what you will owe.

Does Medicare cover chemotherapy side effect medications?

Yes. Medications to manage nausea, low blood cell counts, or other side effects are covered under Part B if given during your infusion appointment, or under Part D if they are pills you take at home. Your copayment follows the same rules as other Part B or Part D drugs.

Can I change my Part D plan if my chemotherapy drug is not covered?

Yes, if you have a may have access to life event — which includes a diagnosis of cancer. You can enroll in a different Part D plan within 63 days of your cancer diagnosis. Contact Medicare at 1-800-MEDICARE to confirm your diagnosis qualifies and to see which plans cover your specific drug.