Medicare does not cover Lexette

Lexette (lexiscan) is a medication used during stress tests to help doctors see how your heart responds to increased blood flow. Medicare Part B does not pay for Lexette when it is given in an outpatient setting, and Part D (prescription drug coverage) does not cover it either. If your doctor orders a Lexette stress test, you will likely pay out of pocket unless your supplemental insurance or a state program covers it.

The reason Medicare excludes Lexette is that it classifies the drug as part of a diagnostic procedure rather than as a standalone prescription. When a hospital or imaging center administers Lexette during your stress test, the facility bills for the procedure as a whole — not for the drug separately. That procedure charge may be covered under Part B, but the Lexette itself is bundled into that cost and not reimbursed as a drug benefit.

Key Takeaways

  • Medicare Part B and Part D do not cover Lexette when used during outpatient stress tests.
  • The cost of Lexette is typically bundled into the stress test procedure charge, which may or may not be covered depending on medical necessity and your specific plan.
  • Supplemental insurance (Medigap) or state pharmaceutical information programs may cover some or all of your out-of-pocket costs.
  • Ask your doctor's office or imaging center what they will bill Medicare and what you will owe before the test.

When the stress test procedure itself may be covered

Medicare Part B covers a pharmacologic stress test (the procedure that uses Lexette) if your doctor documents that you cannot exercise enough to get an accurate heart reading. This might be because of arthritis, lung disease, or another condition that limits your ability to walk on a treadmill. Your doctor must write an order that explains why the test is medically necessary.

If Medicare approves the stress test as medically necessary, the facility will bill Medicare for the procedure. However, this does not mean Lexette itself is covered — it means the test is covered. The Lexette is considered part of the procedure cost, and you may still owe a copay or coinsurance on the entire bill. Ask the imaging center or hospital to tell you in writing what Medicare will pay and what your share will be before you have the test.

What you will likely owe out of pocket

If the stress test is covered, you typically owe 20% coinsurance on the Medicare-approved amount after you have met your Part B deductible for the year. The deductible changes each year — in 2024 it was $240, but you should confirm the current amount with Medicare or your provider.

If the stress test is not covered (for example, if your doctor cannot document medical necessity), you will owe the full facility charge. That charge varies widely by location and facility. A pharmacologic stress test can cost anywhere from $1,000 to $3,000 or more, depending on where you have it done. Call the facility ahead of time and ask for an estimate of what you will owe.

Supplemental insurance and other payment options

If you have a Medigap policy, check your plan documents or call your insurer to ask whether they cover coinsurance on stress tests. Some Medigap plans cover Part B coinsurance, which would reduce what you owe. Others do not. Your policy number and plan letter are on your Medigap card.

If you have limited income, your state may run a pharmaceutical information program that helps pay for medications and diagnostic drugs. Contact your state health department or call 211 to ask whether your state has a program and whether Lexette is covered. You can also ask your doctor's office — many have a social worker or patient advocate who knows about local information programs.

How to find out what you will pay before the test

Do not assume the imaging center or hospital will tell you the cost without asking. Call the facility where you will have the test and give them your Medicare number and any supplemental insurance information. Ask them to check with Medicare what the approved amount is and what your coinsurance will be. Ask them to send you a written estimate.

Also ask whether the facility is in-network for your supplemental insurance, if you have it. An out-of-network facility may charge you more. If the estimate seems high, you can ask your doctor whether the test can be done at a different facility or whether there is an alternative way to evaluate your heart.

What to ask your doctor

Before your doctor orders a Lexette stress test, ask why this test is necessary and whether there are other ways to check your heart. Ask whether the test is covered by Medicare and what you should expect to pay. If your doctor says the test is medically necessary, ask them to document that in your medical record — Medicare needs that documentation to approve payment.

If you are worried about the cost, tell your doctor. They may be able to order the test at a facility that charges less, or they may recommend a different test altogether. Your doctor's office can also help you understand what Medicare will cover and connect you with financial information if you need it.

Frequently Asked Questions

Can I get Lexette covered if I have a different type of Medicare plan?

If you have a Medicare Advantage plan (Part C), coverage rules are different from Original Medicare. Your plan may cover the stress test and Lexette, or it may not. Call your plan's customer service number and ask whether pharmacologic stress tests are covered and what you will owe. The answer depends on your specific plan.

What if my doctor says the test is urgent?

Urgency does not change Medicare's coverage rules. Medicare will still require your doctor to document medical necessity. If the test is truly urgent, the facility may do it right away and sort out billing later, but you should still call ahead to understand what you will owe.

Can I appeal if Medicare denies the stress test?

Yes. If Medicare denies the claim, the facility or your doctor can file an appeal on your behalf. You can also file an appeal yourself. The denial letter will explain how to appeal and what important date you have. Ask your doctor's office to help you with this process.

Will my Medigap insurance pay if Medicare does not cover the test?

Most Medigap plans do not cover services that Medicare does not cover. However, some plans cover a small amount of out-of-pocket costs. Read your plan documents or call your Medigap insurer to ask what they will pay if Medicare denies the claim.

Is there a less expensive way to check my heart if I cannot afford the stress test?

Talk to your doctor about other options. An EKG (electrocardiogram) is much less expensive and may give your doctor the information they need. Your doctor can also order an echocardiogram or other tests depending on your symptoms. Ask what each test costs and what each one will tell your doctor.