Paying for Cancer Prevention

Prophylactic or risk-reducing surgery is recommended for certain people at increased risk of cancer due to an inherited genetic mutation. Although these surgeries are preventive, health insurers do not cover 100 percent of the cost. Deductibles, coinsurance and copays apply. In some cases, prophylactic surgery may not be covered at all. Be sure to understand your insurance benefits before moving forward with risk-reducing surgery to plan appropriately for out-of-pocket costs.

Risk-reducing medication, also known as chemoprevention, may be recommended for some people at increased risk of certain cancers, including, but not limited to:

• breast cancer
• ovarian cancer
• endometrial/uterine cancer

Private insurance

Risk-Reducing Surgery

Most private insurers cover risk-reducing (prophylactic) surgery for certain high-risk people.

The majority of private health plans cover risk-reducing surgeries, such as mastectomy, hysterectomy, salpingo-oophorectomy, colectomy and gastrectomy for people with an inherited genetic mutation linked to a significantly increased risk of cancer.

For those without a known hereditary mutation, some insurers will cover surgery for individuals who have a high lifetime risk of cancer as identified by models that assess family history of cancer and other factors.

The Women’s Health and Cancer Rights Act (WHRCA) requires that most group health insurers that cover mastectomies must also cover breast reconstruction and breast prostheses.

Although these surgeries are often covered by health insurers, they are not reimbursed at 100 percent. Some people encounter high out-of-pocket costs due to deductibles, coinsurance and copayments. Using in-network rather than out-of-network providers can minimize costs.

Medical Necessity

Some health plans do not consider prophylactic surgery medically necessary, even if you have a high risk of cancer. Self-funded and short-term health plans are more likely to take this stance—especially for risk-reducing mastectomies. These insurers may deny coverage if an individual decides to remove both healthy breasts to reduce their risk of breast cancer. Coverage may also be denied when a person has a mastectomy to treat breast cancer in one breast and wants to also remove the opposite healthy breast.

If your insurer denies coverage of your surgery, we encourage you to file an appeal. Ask your surgeons and other healthcare providers to write letters of medical necessity to explain your high-risk status. Visit our Health Insurance Appeals webpage for downloadable sample appeal letters citing national, evidence-based medical guidelines. 

Chemoprevention

Most private insurers cover chemoprevention.

Ovarian, Endometrial and Uterine Cancer

Hormonal contraceptives, such as birth control pills or patches, have been shown to lower the risk of ovarian and endometrial/uterine cancer. The Affordable Care Act (ACA) requires most private health insurers to pay for FDA-approved contraceptives with no out-of-pocket cost to the patient.

Federal law also requires insurance coverage of contraceptives for federal employees and their dependents. Some health plans limit coverage to certain brands or generic versions. Your health insurance provider can confirm the types of birth control they cover. 

Some health insurance plans, including self-funded, short-term and exempt “religious employer” plans, are not required to abide by all ACA rules and may have different policies regarding coverage of contraceptives. Still, most insurers cover hormonal contraceptives.

Breast Cancer

Tamoxifen, raloxifene and aromatase inhibitors are FDA-approved medications for breast cancer risk reduction in high-risk women. The Affordable Care Act (ACA) requires most private health plans to pay for these drugs with no out-of-pocket expenses for women ages 35 and older who meet the U.S. Preventive Services Task Force (USPSTF) guidelines.

The law does not apply to women below age 35, and some high-risk women may not be eligible, even if they have an inherited mutation that increases their risk of cancer. In these cases, health insurers generally cover the medications for high-risk women, but deductibles, coinsurance or copays may apply.

Medicare

Risk-Reducing Surgery

Medicare typically requires signs or symptoms of cancer to qualify for surgery. For this reason, Medicare generally does not cover preventive surgeries, although people in some regions of the country have succeeded in getting coverage.

Visit the Medicare website or call 1-800-MEDICARE (1-800-633-4227) to learn more about what your plan covers and how to manage claims and appeals.

Chemoprevention

Ovarian, Endometrial and Uterine Cancer

Hormonal contraceptives, such as birth control pills or patches, have been shown to lower the risk of ovarian and endometrial/uterine cancer. If you have Medicare Part D prescription drug coverage, your benefits may pay for some types of hormonal contraceptives. Each Medicare D plan has a formulary (a list of covered prescription drugs). The type of birth control your plan covers is listed on its formulary. Formularies typically have at least two drug options for every category: a generic brand and a brand name. Pricing may vary, based on brand name and generic options, and whether you use an in-network pharmacy or a mail-order service.

Breast Cancer

All Medicare Part D and Medicare Advantage plans cover tamoxifen, raloxifene and aromatase inhibitors with little or no copay.

Medications, including statins (typically used to lower cholesterol levels) and aspirin, have been studied for their potential role in reducing the risk of certain cancers, preventing recurrence and/or increasing survival. While Medicare may not completely cover the cost of these medications, they are often available with a small copay or out-of-pocket cost.

Visit the Medicare website or call 1-800-MEDICARE (1-800-633-4227) to learn more about the medications covered under your plan.

Medicaid

Risk-Reducing Surgeries

Medicaid coverage of risk-reducing surgeries, such as mastectomy (removal of breasts), hysterectomy (removal of the uterus) or salpingo-oophorectomy (removal of the ovaries and fallopian tubes), as well as breast reconstruction after mastectomy, varies by state. 

Contact your Medicaid office to learn more about access to these services in your state.

Chemoprevention

Ovarian, Endometrial and Uterine Cancer

While eligibility and benefits vary by state, most Medicaid programs offer free contraceptives, although they are not required to cover all FDA-approved birth control methods. Some states have expanded family planning services and access to hormonal contraceptives for low-income people who would not otherwise be eligible for Medicaid.

Breast Cancer

State Medicaid programs must cover all of a manufacturer’s drugs if it has a Medicaid rebate agreement. This requirement ensures broad access to cancer-related drugs and therapies, including those that reduce cancer risk.   

Contact your Medicaid office to learn more about access to risk-reducing medications in your state.