COVERAGE
No cost sharing for colonoscopy following a positive Cologuard® result1,2*
Follow-up colonoscopy coverage
There is no cost sharing for colonoscopy following a positive Cologuard result1,2
January 2022
The federal government issued guidance making it clear that a colonoscopy after a positive noninvasive CRC screening test should be considered part of the screening process.1,2†
2023 Policy Changes
Positive results from a noninvasive stool-based test, including the Cologuard test, qualify for coverage of follow-up colonoscopy with no cost sharing.1,2†
As of 2023, Affordable Care Act (ACA) and Centers for Medicare & Medicaid Services (CMS) guidance requires coverage to encourage CRC screening by reducing financial barriers.1,2
Follow-up Colonoscopy Summary Guide
This guide for Providers and Medical Offices, from the American Gastroenterological Association and Fight CRC, provides more information about this regulatory change, what it means for providers, and how to code the change correctly.
The Cologuard test is covered by Medicare and Medicare Advantage with no co-pay or deductible for eligible patients.1,3
Nationwide, over 96% of all Cologuard patients 45+ have no out-of-pocket costs for screening4‡
Most insured patients pay $0 for the Cologuard test4‡
Eligible patients who are actively enrolled in any state Medicaid program can access the Cologuard test. No payment will be expected from the patient unless the plan requires a co-pay.1§
Cologuard Ordering Information
For ease of ordering, the Cologuard CPT code is 81528. Find more important ordering information on the How to Order page.
Cologuard coverage
Find a specific insurer to see if the Cologuard test is covered for your eligible patients.
Exact Sciences is committed to helping eligible patients access and afford CRC screening
Insurance support:
- Verification of benefits, as requested
- Patient-assisted insurance appeals
Financial support programs:
- Flexible payment plans
- Financial assistance program, based on eligibility
Customer Care Center:
- Available to providers and patients
- Available via chat or by phone at 1-844-870-8870
Support for your eligible patients
Explore the comprehensive support that the Cologuard test offers you and your patients
- Only your patients’ insurers can confirm coverage of a follow-up colonoscopy.1,2
- For patients with traditional Medicare, a colonoscopy after a positive Cologuard result is still a screening colonoscopy based on updated Centers for Medicare & Medicaid Services regulations, effective January 1, 2023. Medicare does not apply cost sharing to screening colonoscopy. This update does not apply to commercial plans with exempted status.1,2
- Exact Sciences estimate based on historical patient billing. Rate of coverage varies by state and region. 95% of patients aged 45-49 pay no out-of-pocket costs with the Cologuard test. Exceptions for coverage may apply; only your patients’ insurers can confirm how the Cologuard test would be covered.4
- The Cologuard test is a preventive service for NY Medicaid and members have no financial responsibility.1