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

If you have Original Medicare (Part A and Part B), chemotherapy is covered as a medically necessary cancer treatment. Part B covers chemotherapy drugs given in a doctor's office or hospital outpatient setting. Part A covers chemotherapy if you are admitted to a hospital as an inpatient. If you have a Medicare Advantage plan (Part C), your coverage works differently — your plan must cover chemotherapy, but your out-of-pocket costs and which drugs are covered depend on your specific plan's rules.

The key difference is what you pay. With Original Medicare, you typically pay 20% of the approved amount for chemotherapy after you meet your Part B deductible. With Medicare Advantage, you may pay a copay per visit or coinsurance, depending on your plan. Some Medicare Advantage plans have an annual out-of-pocket maximum; Original Medicare does not.

Key Takeaways

  • Original Medicare Part B covers chemotherapy drugs given in outpatient settings after you pay the Part B deductible and 20% coinsurance.
  • Medicare Advantage plans must cover chemotherapy, but your copays, coinsurance, and which drugs are covered vary by plan.
  • Chemotherapy given during a hospital inpatient stay is covered under Part A, with costs depending on your hospital deductible and length of stay.
  • Some chemotherapy drugs may require prior authorization from Medicare or your plan before treatment begins.
  • Prescription chemotherapy pills taken at home are covered under Part D (prescription drug coverage) if you have it, with your copay based on the drug's tier.

How Original Medicare Covers Chemotherapy

Under Original Medicare Part B, chemotherapy administered in a hospital outpatient department, cancer center, or doctor's office is covered as a medically necessary service. You pay 20% of the Medicare-approved amount after you have met your annual Part B deductible (which is $240 in 2024, though this amount changes yearly). The provider bills Medicare first, and Medicare pays its 80% share directly to the provider.

If your chemotherapy requires a hospital stay, Part A covers the inpatient costs. You pay a hospital deductible (which varies by length of stay) for the first 60 days, then coinsurance for days 61 through 90, and higher coinsurance for any days beyond 90. The chemotherapy drugs themselves are included in the hospital bill — you do not pay separately for the drugs when admitted as an inpatient.

Some chemotherapy drugs may require prior authorization, meaning your doctor must contact Medicare before treatment starts to confirm the drug is covered for your specific diagnosis. This is not a denial — it is a verification step. If Medicare denies the request, your doctor can appeal or discuss alternative drugs that are covered.

Medicare Advantage Coverage for Chemotherapy

All Medicare Advantage plans are required by law to cover chemotherapy as a medically necessary treatment. However, the amount you pay out of pocket varies widely by plan. Some plans charge a copay per chemotherapy visit (for example, $50 per infusion), while others charge coinsurance (a percentage of the cost). A few plans may waive the copay for cancer treatment, though this is less common.

Medicare Advantage plans also maintain a formulary — a list of covered drugs. Your plan may cover some chemotherapy drugs but not others, or may require you to try a different drug first before covering your doctor's first choice. If your prescribed drug is not on the formulary, your doctor can request an exception, and the plan can approve it if they agree the drug is medically necessary.

Most Medicare Advantage plans have an annual out-of-pocket maximum. Once you reach this limit (amounts vary by plan, typically between $6,700 and $10,000), the plan pays 100% of covered services for the rest of the year. Original Medicare has no out-of-pocket maximum, which means your costs can continue to rise if you need extensive treatment.

Chemotherapy Pills and Part D Coverage

If your cancer treatment includes chemotherapy pills or tablets taken at home, these are covered under Part D (prescription drug coverage), not Part B. Part D is optional, and you must have it to cover prescription drugs. If you do not have Part D, you will pay the full cost of oral chemotherapy out of pocket.

With Part D, you pay a copay or coinsurance based on which tier the drug is on. Specialty drugs — a category that includes many newer chemotherapy pills — are usually on the highest tier and may cost $100 to $500 per month or more, depending on your plan. Some plans offer copay information or reduced copays for cancer drugs, so it is worth asking your plan directly.

If your Part D plan does not cover your prescribed chemotherapy pill, your doctor can request a formulary exception. The plan has 72 hours to respond to urgent requests. If the plan denies the exception, you have the right to appeal.

Costs You Should Expect

Your actual out-of-pocket cost for chemotherapy depends on several factors: which Medicare plan you have, which chemotherapy drugs you receive, how many infusions or doses you need, and whether the drugs require prior authorization or formulary exceptions.

With Original Medicare Part B, expect to pay 20% coinsurance after your deductible. If a chemotherapy drug costs $5,000 per infusion and you receive four infusions, your 20% share would be $4,000 total (after deductible). With Medicare Advantage, you might pay $50 to $200 per visit instead, but your plan may not cover all the drugs your doctor recommends.

Many cancer centers and hospitals have financial counselors who can estimate your costs based on your specific plan and treatment plan. Ask to speak with a financial counselor before treatment begins — they can also tell you about copay information programs run by drug manufacturers or nonprofits that may reduce what you pay.

Prior Authorization and Coverage Decisions

Before your chemotherapy begins, your doctor's office will often submit a request to Medicare (if you have Original Medicare) or your Medicare Advantage plan to confirm the drug and treatment plan are covered. This is called prior authorization. Most requests are approved within a few days.

If Medicare or your plan denies the request, your doctor receives a written explanation of why. Your doctor can then appeal the decision, provide additional medical information, or discuss alternative drugs that are covered. You have the right to be involved in this conversation — ask your doctor to explain the denial and what options are available.

Some chemotherapy drugs are covered only for certain types of cancer or only after other treatments have been tried first. If your drug falls into this category, your doctor will need to document that you meet these conditions before the plan will cover it. This is not a refusal to treat you — it is a coverage rule you can work around with your doctor's help.

Getting Help Understanding Your Coverage

Your Medicare plan should send you a document called the Summary of Benefits and Coverage or Evidence of Coverage. This document lists what is covered, what you pay, and any limits or rules. For chemotherapy specifically, look for sections on "cancer treatment," "infusion therapy," or "specialty drugs." If you cannot find the information, call your plan's customer service number — it is on your insurance card.

You can also contact 1-800-MEDICARE (1-800-633-4227) to ask questions about Original Medicare coverage. If you have a Medicare Advantage plan, call your plan directly. Both services are free and available 24 hours a day, seven days a week.

If you are struggling to pay for chemotherapy, ask your cancer center's social worker or financial counselor about copay information programs. Many drug manufacturers offer programs that reduce or eliminate your copay if your income is below a certain level. Organizations like CancerCare and the American Cancer Society also offer financial information for cancer treatment.

Frequently Asked Questions

Does Medicare cover all types of chemotherapy drugs?

Medicare covers chemotherapy drugs that the FDA has approved for cancer treatment and that your doctor prescribes as medically necessary for your diagnosis. However, some drugs may require prior authorization, and some Medicare Advantage plans may not cover every drug. If your prescribed drug is not covered, your doctor can appeal or request an exception.

What if I switch from Original Medicare to a Medicare Advantage plan during chemotherapy?

You can switch plans during the annual open enrollment period (October 15 to December 7) or if you have a may have access to life event. If you are in the middle of chemotherapy, ask your new plan whether your current drugs and treatment plan are covered before you switch. Some plans may have different copays or may not cover your specific drug.

Do I have to pay for chemotherapy if I have both Medicare and Medicaid?

If you have both Medicare and Medicaid (called "dual may be able to access"), Medicaid may help pay your Medicare copays and deductibles. The amount Medicaid covers varies by state. Contact your state Medicaid office to learn what information you may receive for cancer treatment costs.

Are there limits on how much chemotherapy Medicare will pay for?

Medicare does not limit the number of chemotherapy treatments you can receive if they are medically necessary for your cancer. However, your doctor must document that each treatment is needed. If Medicare questions whether a treatment is necessary, your doctor can appeal the decision.

What happens to my chemotherapy coverage if I reach my Part D out-of-pocket maximum?

Once you reach your Part D out-of-pocket maximum (the amount varies by plan), your plan pays 100% of covered prescription drugs for the rest of the calendar year. This applies to chemotherapy pills as well as other medications. Your plan should notify you when you are close to reaching this limit.