A Guide to Medicare Coverage for Prostate Exams and Treatment
Did you know that prostate cancer is the second-most common cancer that occurs in men in the United States? Thankfully, there are preventive measures that men can take to detect, prevent, and treat prostate cancer.
Medicare covers prostate specific antigen (PSA) tests and digital rectal exams for prostate cancer screenings. It also covers treatment for prostate cancer if you’ve been diagnosed.
Key takeaways:
Medicare covers PSA tests and digital rectal exams for prostate cancer screenings once every 12 months.
PSA tests are free while digital rectal exams have a 20% coinsurance after you meet your Part B deductible
Medicare coverage also extends to prostate cancer treatment, like surgery, radiation, chemotherapy, medication, and other services.
Why older men should pay attention to prostate health
Your risk of developing prostate cancer increases with age. 6 in 10 prostate cancer diagnoses occur in men who are 65 and older. As men age, they may experience symptoms related to prostate conditions such as benign prostatic hyperplasia (BPH) or prostatitis (inflammation of the prostate). These symptoms can include frequent urination, difficulty urinating, weak urine stream, blood in urine or semen, and pelvic pain. BPH, prostatitis, and other prostate conditions can be risk factors for developing prostate cancer.
Prostate conditions can also affect your quality of life. Symptoms can get in the way of daily activities, affect your quality of sleep, impact sexual function, and lead to emotional stress. Additionally, advanced cases of prostate cancer can affect bone health and decrease your mobility.
While prostate cancer can be serious, it’s not often terminal. That’s because, in recent years we’ve seen advances in prevention and treatment for prostate cancer. Your Medicare coverage can help you prioritize prostate cancer screenings for early detection and treatment.
What is involved in prostate cancer screenings?
There are two main types of prostate cancer screening tests: a prostate-specific antigen (PSA) test and digital rectal examination (DRE).
Prostate-specific antigen (PSA) test
A prostate-specific antigen test is a blood test that measures levels of PSAs, proteins produced by the prostate gland. Elevated PSA levels signal a likelihood of prostate cancer, benign prostatic hyperplasia (BPH), prostatitis, or other prostate conditions. For a PSA test, you simply go to your healthcare provider to get blood drawn.
Digital rectal examination (DRE)
During a digital rectal examination, a healthcare provider checks your rectum to feel the prostate gland for any abnormalities. If your doctor detects lumps, hardness, or asymmetry, it could indicate a prostate condition.
These tests are initial screenings to determine if the presence of prostate cancer is likely. They aren’t typically used to get a definitive diagnosis. You may have to undergo additional testing, such as a prostate biopsy, to confirm you have prostate cancer.
Does Medicare cover a PSA test?
Yes, Medicare covers both a PSA test and digital rectal exam.
For a digital rectal exam, you’ll pay 20% of the cost of the exam after you meet your Part B deductible. If you choose to receive the exam at a hospital outpatient setting, you’ll also pay an additional hospital copay.
For a PSA test, you won’t have to pay anything for an annual blood draw. If your doctor doesn’t accept the Medicare-approved costs of the service, you may have to pay a fee for the doctor’s time, but not for the PSA test.
How often does Medicare cover PSA tests?
Medicare covers PSA tests and digital rectal exams once every 12 months for men over 50, starting the day after your 50th birthday. You can receive coverage for both tests once a year.
Does Medicare cover MRIs for prostate screenings?
If your doctor sees abnormalities from a PSA or DRE, they may order an MRI or prostate biopsy to confirm a diagnosis for prostate cancer. Both of these services are covered by Medicare. You’ll pay your Part B deductible and 20% of the cost of the MRI or biopsy.
An MRI scan is a non-invasive imaging device that doctors use to look at the prostate gland and surrounding tissues for tumors and cancerous tissues. Doctors perform a prostate biopsy to collect tissue samples from the prostate gland and examine them under a microscope. The biopsy helps doctors formally diagnose prostate cancer. You may have to pay an additional copay if you receive either of these tests at an inpatient facility.
Both MRIs and prostate biopsies are typically recommended when PSAs or DREs suggest the possibility of prostate cancer.
Medicare prostate cancer treatment coverage
Medicare has comprehensive coverage for cancer treatment. If you are diagnosed with prostate cancer, you may have to undergo prostate surgery, radiation therapy, hormone therapy, chemotherapy, immunotherapy, or other treatment plan depending on your situation.
With Medicare, you have coverage for all of these services under your Part B insurance. Like most services, you’ll pay a 20% coinsurance after you meet your Part B deductible.
Does Medicare cover prostate surgery?
Prostate surgery involves removing cancerous growths from the prostate or partially or completely removing the prostate gland (prostatectomy).
Medicare helps pay for prostate surgery, including any preparation or follow-up care. Depending on your situation and what your surgery takes place, you may receive care in an outpatient or inpatient facility. Where you receive surgery determines how much you’ll have to pay.
If your doctor orders additional treatment, like chemotherapy, or DME after your surgery, your Part B insurance covers these services.
A prescription drug plan will help cover the drugs you need to help you recover after the surgery. Make sure that your formulary includes the medications you need or ask your doctor to prescribe alternatives that are covered.
Understanding your Medicare coverage
Prostate health is an important part of your healthcare that you shouldn’t overlook, and Medicare can help you prioritize preventive screenings. Get in touch with a Medicare Advisor to learn about all your Medicare coverage options. Call us at 855-900-2427 or schedule a time to chat.