Does Medicare Cover PCA3 Tests?

The prostate cancer antigen 3 gene (PCA3) test looks for a genetic marker that helps to determine how high your risk is for having prostate cancer. It has a similar purpose as a PSA test but measures different things.

So a common question many people have is, “does Medicare cover PCA3 tests?” In this article, we answer that question in clear, plain English. You will also find the average costs of PCA3 tests and other helpful info.

The short answer is no. In most cases, Medicare will not cover the cost of PCA3 tests. That said, there may be some situations where you can get these costs covered. Below we’ll take a closer look at this to see when you might be able to get Medicare to pay for your PCA3 tests.

Original Medicare

Original Medicare (Medicare Part A and Part B) does not provide coverage for PCA3 tests. Medicare does not consider a PCA3 test medically necessary if your healthcare provider orders it to biopsy your prostate. That procedure is only considered investigational rather than medically necessary.

Original Medicare may only provide coverage for your PCA3 test if you underwent a biopsy/biopsies and all of the results are negative. Original Medicare may also provide coverage when you or your healthcare provider wants to avoid repeat biopsies.

Though Original Medicare does not provide coverage for a PCA3 test, they do cover prostate cancer screenings. Coverage for prostate cancer screenings is provided by Medicare Part B. Medicare Part B provides coverage for one prostate cancer screening every 12 months or one year.

However, you may only be eligible for a prostate cancer screening if you are 50 years of age or older. The annual prostate cancer screening includes:

Digital Rectal Exam or DRE
Prostate-Specific Antigen or PSA test

Medicare Part B covers 100 percent of the costs of your yearly prostate cancer exam.

Aside from the yearly prostate cancer exam, Medicare Part B also provides coverage for diagnostic prostate cancer screenings. Medicare Part B will provide coverage for your diagnostic prostate cancer exam if your healthcare provider deems it necessary to undergo the test more than once a year.

Medicare Part B covers 80 percent of the costs of your diagnostic prostate cancer screening. You will pay for the remaining 20 percent.

Part C Coverage for PCA3 Tests

Just like with Original Medicare, Medicare Advantage plans (Medicare Part C) also do not provide coverage for PCA3 tests. Medicare Advantage plans cover everything Original Medicare covers and typically also offers some additional benefits. However, coverage and out-of-pocket costs will vary depending on the specifics of your pan.

Medicare Part C will only provide coverage for a PCA3 test if it meets the same requirements stated above.

How Much Does A PCA3 Test Cost?

Undergoing a PCA3 test may cost somewhere from $200 to $450. The exact price will vary depending on the manufacturer of the test.

Note: Medicare coverage changes all the time. And your specific coverage may vary from plan to plan for Medicare Advantage and Medigap plans. Always be sure to double check with your health care provider and/or Medicare insurance provider about what your plan covers and what it does not.