Medicare Part B covers Cologuard if your doctor orders it and you meet specific requirements

Medicare Part B pays for Cologuard (a stool-based DNA test that screens for colorectal cancer) when a doctor has ordered it for you. You do not pay anything out of pocket if the test is done at a lab that accepts Medicare assignment. The test must be ordered by your doctor — you cannot order it yourself — and you must be between 50 and 85 years old with no symptoms of colorectal cancer.

Cologuard is covered as a screening tool, not a diagnostic tool. That means Medicare will pay for it if you are getting it to check for cancer before any symptoms appear. If your doctor is using it to investigate symptoms you already have, coverage rules may differ, and you should ask your doctor's office to check with Medicare before the test.

Key Takeaways

  • Your doctor must order Cologuard for you; Medicare does not cover it if you order it yourself or buy it over the counter.
  • You must be between 50 and 85 years old with no current symptoms of colorectal cancer for Medicare to cover the test.
  • Medicare Part B covers the full cost when the lab accepts Medicare assignment, so you pay nothing out of pocket.
  • Medicare covers Cologuard once every three years as a screening test, not more frequently.

How the ordering process works

Your doctor decides whether Cologuard is right for you based on your age, health history, and whether you have had other colorectal cancer screening tests. During a regular visit, your doctor can order the test directly. The doctor's office will send the order to a lab that participates in Medicare, and the lab will mail you a collection kit at home.

You complete the test at home by collecting a stool sample and mailing it back to the lab in the prepaid envelope. The lab sends results to your doctor, who discusses them with you. If the results are normal, you typically do not need another Cologuard test for three years. If results are abnormal, your doctor may recommend a colonoscopy to look inside your colon.

What you pay and what Medicare pays

When your doctor orders Cologuard from a Medicare-participating lab, Medicare Part B covers the full cost of the test. You pay nothing — no copay, no coinsurance, no deductible. This is true even if you have not yet met your Part B deductible for the year.

If you use a lab that does not accept Medicare assignment, or if you buy a Cologuard kit directly without a doctor's order, you will pay the full retail price out of pocket, and Medicare will not reimburse you. Always ask your doctor's office to order the test through a Medicare-participating lab to avoid unexpected costs.

Age and frequency limits

Medicare covers Cologuard for people between 50 and 85 years old. If you are younger than 50 or older than 85, Medicare does not cover it, though your doctor may still recommend it and you could choose to pay for it yourself.

Medicare covers one Cologuard test every three years. If you have the test done and it comes back normal, you cannot have another one covered by Medicare until three years have passed. If your results are abnormal and your doctor recommends a colonoscopy, the colonoscopy is a separate procedure with its own coverage rules.

When Medicare does not cover Cologuard

Medicare does not cover Cologuard if you have symptoms of colorectal cancer, such as blood in your stool, persistent abdominal pain, or unexplained weight loss. In those cases, your doctor would order a diagnostic test instead, and the coverage rules are different. Tell your doctor about any symptoms before the test is ordered.

Medicare also does not cover Cologuard if you have a personal or family history of colorectal cancer, certain polyps, or inflammatory bowel disease. People with those risk factors usually need colonoscopy instead of Cologuard, and colonoscopy has different coverage rules. Your doctor will determine which screening method is appropriate for your situation.

Cologuard versus colonoscopy under Medicare

Medicare covers both Cologuard and colonoscopy as screening tests for colorectal cancer, but they work differently and have different coverage rules. Cologuard is a stool test you do at home; colonoscopy is a procedure where a doctor looks inside your colon with a camera. Both are covered at no cost to you when ordered by your doctor.

Colonoscopy can both screen for cancer and remove polyps during the same visit, which is why some doctors prefer it. Cologuard is simpler and less invasive, but if it finds something abnormal, you will need a colonoscopy anyway to investigate. Your doctor can help you decide which test makes sense for your health history and preferences.

How to make sure your test is covered

Before your doctor orders Cologuard, ask the office staff to confirm that the lab they use accepts Medicare assignment. You can also call Medicare at 1-800-MEDICARE to verify coverage for your specific situation. Provide your age, whether you have symptoms, and when you last had colorectal cancer screening.

Keep a copy of your doctor's order and any paperwork the lab sends you. If you receive a bill after the test, contact the lab and Medicare to find out why. Most billing problems happen when the lab does not process the Medicare claim correctly, and the lab can usually fix it.

Frequently Asked Questions

Can I order Cologuard myself without a doctor's order?

No. Medicare only covers Cologuard when your doctor orders it. If you order it yourself or buy it directly, Medicare will not pay for it, and you will owe the full cost. You must see your doctor first and have them place the order through a Medicare-participating lab.

What happens if my Cologuard test comes back abnormal?

Your doctor will discuss the results with you and usually recommend a colonoscopy to examine your colon more closely. The colonoscopy is a separate procedure, and Medicare covers it under different rules. Your doctor's office can explain what to expect and help you schedule the follow-up test.

Does Medicare cover Cologuard if I am over 85?

Medicare does not cover Cologuard for people over 85. However, your doctor may still recommend it based on your health, and you could choose to pay for it yourself. Talk to your doctor about whether screening makes sense for you at your age.

How often can I have Cologuard covered by Medicare?

Medicare covers one Cologuard test every three years if your results are normal. If you want the test more frequently, you would need to pay for it yourself. Your doctor can tell you whether more frequent screening is medically necessary for your situation.

Will I have to pay anything if my doctor orders Cologuard?

No, if your doctor orders it from a Medicare-participating lab and you meet all the coverage requirements. You will not owe a copay, coinsurance, or deductible. The only way you would pay is if the lab does not accept Medicare assignment or if you do not meet the age or symptom requirements.