Does Medicare Cover Cologuard? 

Cologuard is the registered trademark for a non-invasive, at-home test for colon cancer produced by the Exact Sciences Corporation in the United States. Anyone can take this test at home, but it’s mainly intended for adults over 45 who have an average risk for colorectal cancer. 

Cologuard works by detecting specific DNA markers and blood in a stool sample you take at home, and then send by mail to a lab. Medical professionals advise that Cologuard shouldn’t take the place of a colonoscopy for those who are at high risk for colon cancer, nor should you use it if you have had adenomas, inflammatory bowel disease, hereditary syndromes, or a personal or family history of colorectal cancer. 

It’s a good idea to consult your health care provider before testing yourself with Cologuard, and if you decide to give it a try, your Medicare insurance might help you cover a part of your expenses.  

How do your Medicare benefits cover Cologuard? 

If you’re enrolled in Original Medicare Part A (hospital insurance) and Part B (medical insurance), your Part B benefits cover multi-target stool DNA tests like Cologuard if you meet all the following conditions: 

  • You are between the ages of 45 and 85.
  • You don’t currently have any symptoms of colorectal cancer such as lower gastrointestinal pain, blood in your stool, a positive guaiac fecal occult blood test, or a fecal immunochemical test. 
  • Your risk for developing colorectal cancer is average. This means that you don’t have a personal history of adenomatous polyps, colorectal cancer, or an inflammatory bowel disease such as Crohn’s or ulcerative colitis. Having an average risk also means you don’t have a family history of colorectal cancer, adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer. 

Original Medicare Part B pays 100 percent of the cost for a multi-target stool DNA test if your prescribing physician or health care provider accepts Medicare assignment. 

If you have a Medicare Advantage (Part C)plan, your provider must cover the same benefits as Original Medicare Parts A and B. If you qualify for coverage of a Cologuard test, your provider must cover it. However, you may have to pay coinsurance or a copayment, depending on the type of Medicare Advantage plan you have. 

How does a Cologuard test work? 

Before you can order a Cologuard test you need to get a prescription from your health care provider which you send together with a completed order form provided by the company at their online site. 

When the kit is delivered to you, you’ll find all the tools, containers, solutions, and instructions inside. After collecting your stool sample and preserving it as instructed, you fill out the form that’s included in the kit with your personal information. Then you ship it back to the company, within 24 hours, using the prepaid shipping label and box provided with the kit. 

The Cologuard lab evaluates your stool sample and prepares a report with the results. This report is then sent directly to your health care provider who can explain them to you and prescribe further testing if necessary. 

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