Learn how Medicare covers low-volume PEG bowel prep kits, which plans may include them, and what out-of-pocket costs to expect before your colonoscopy
KEY TAKEAWAYS
Low-volume PEG bowel preparation options require patients to drink less prep solution before a colonoscopy—typically less than 1–2 liters, compared with traditional bowel prep regimens that may require around 4 liters. This smaller volume may be easier for some patients to tolerate.
Although the Affordable Care Act (ACA) requires coverage of recommended colorectal cancer screening colonoscopies and associated preparation, coverage for certain low-volume PEG bowel prep products can vary. Some Medicare plans may still have higher out-of-pocket costs for these prescription bowel prep options.
When covered, low-volume PEG bowel prep kits are generally processed through Medicare Part D (prescription drug coverage), while the colonoscopy procedure itself is covered under Medicare Part B (medical coverage). Patients should check their specific plan benefits to understand coverage requirements and potential costs.
Although Medicare covers colonoscopy procedures, coverage for colonoscopy preparation kits is not always the same across all products.
Medicare Part D generally covers prescription colonoscopy prep kits, but coverage depends on the specific plan. This means:
- One bowel prep kit may be fully covered.
- Another prep option may require a copay or other out-of-pocket cost.
Some patients prefer low-volume bowel prep kits because they require drinking much less liquid compared with traditional preparation methods. However, the cost of these options can vary depending on Medicare Part D coverage and plan restrictions.
Understanding what your plan covers, your expected out-of-pocket costs, and available savings options can help you choose a bowel prep option that fits both your medical needs and budget.
What are low-volume PEG preps?
Polyethylene glycol (PEG) is an osmotic laxative that works by drawing water into the intestines. This helps soften stool and stimulates bowel movements, making it easier to clear the colon before a colonoscopy.
A thorough bowel cleanse is essential because it removes stool and residue, allowing healthcare providers to have a clear view of the colon and identify abnormalities such as polyps or other concerns.
Traditional vs. Low-Volume Colonoscopy Prep
Traditional high-volume bowel prep solutions typically require patients to drink about 4 liters (around 1 gallon) of solution. These preparations usually contain:
- Laxatives to empty the bowel
- Electrolytes to help reduce the risk of dehydration during the cleansing process
Low-volume bowel prep options are newer alternatives that require significantly less liquid, often less than 1–2 liters of prep solution. Many patients find these options easier to tolerate.
Common low-volume PEG-based bowel prep kits include:
- MoviPrep
- Plenvu
Other lower-volume or non-PEG bowel preparation options include:
- Clenpiq
- Sutab (oral tablets)
- Suprep
Split-Dose Bowel Prep
Instead of taking the entire preparation the night before a colonoscopy, many healthcare providers now recommend a split-dose approach.
According to Savita Srivastava, MD, a gastroenterologist and microbiome specialist, this approach involves:
- Taking the first dose the evening before the procedure
- Taking the second dose early the next morning, typically 4–5 hours before arrival
Patients should also continue drinking the recommended amount of clear liquids because adequate hydration helps the bowel prep work effectively and supports electrolyte balance during the cleansing process.
Does Medicare cover low-volume PEG preps?
Although the Affordable Care Act (ACA) requires coverage for recommended colonoscopy screenings and associated bowel preparation without cost-sharing in many situations, some patients still face out-of-pocket expenses for certain colonoscopy prep options.
According to the American Gastroenterological Association, approximately 83% of Medicare claims for colonoscopy prep kits include some out-of-pocket costs.
This means that while Medicare may cover bowel preparation kits, the amount a patient pays can depend on factors such as:
- The specific bowel prep product prescribed
- The patient’s Medicare Part D plan
- Formulary placement and coverage rules
- Copays or cost-sharing requirements
Patients who prefer low-volume PEG bowel prep kits may want to check their insurance coverage before filling a prescription to understand their expected costs and available alternatives.
Does Medicare Part D cover low-volume PEG preps?
Because PEG bowel preparation kits are prescription medications that patients fill at a pharmacy and take at home, they are typically covered under Medicare Part D, which provides prescription drug coverage.
However, Part D coverage does not always mean the medication is fully covered. The amount a patient pays depends on factors such as:
- The specific Medicare Part D plan
- The plan’s drug formulary
- The medication tier placement
- Whether the patient has reached their annual Part D deductible
According to Dr. Srivastava, many patients face significant costs for brand-name low-volume PEG preparations because of higher copays or deductibles. Some patients may pay more than $100 out of pocket for these bowel prep options.
Medicare Spending on Low-Volume PEG Preps
In 2023, Medicare spending included:
-
Plenvu: More than $8 million in Medicare coverage spending
- Approximately $49 per dose covered by Medicare
- Average price: about $209
-
MoviPrep: About $73,000 in Medicare coverage spending
- Approximately $131 per dose covered by Medicare
- Average price: about $179
Even with Medicare coverage, many patients still pay part of the cost because the covered amount may not equal the full retail price.
Why Costs Can Be High
Many Medicare Part D plans place brand-name low-volume PEG bowel prep kits in higher formulary tiers.
Generally:
- Lower tiers → Generic medications and preferred drugs with lower copays
- Higher tiers → Brand-name or non-preferred medications with higher out-of-pocket costs
Because every Medicare plan has its own formulary and pricing structure, coverage and patient costs can vary widely. Patients should review their specific Part D plan or speak with their healthcare provider about covered bowel prep options before a colonoscopy.
Does Medicare Part B cover colonoscopy prep?
Medicare Part B generally covers medical services, procedures, and treatments provided in a healthcare setting. For colonoscopy procedures, this typically includes:
- The colonoscopy itself
- Required anesthesia services (when covered under Medicare guidelines)
However, colonoscopy preparation kits are not covered under Medicare Part B because they are prescription medications that patients obtain from a pharmacy and take at home. Since they are not administered in a healthcare provider’s office, they fall under Medicare Part D prescription drug coverage instead.
This means patients should review their Medicare Part D plan benefits to understand whether their prescribed bowel prep kit is covered and what out-of-pocket costs may apply.
Does Medicare Advantage cover low-volume preps?
Medicare Advantage (also known as Medicare Part C) combines benefits from Medicare Part A and Part B, and many plans also include Part D prescription drug coverage.
For colonoscopy preparation kits:
- Medicare Advantage plans that include Part D will generally provide some level of coverage for prescription bowel prep kits, including PEG-based preparations.
- Medicare Advantage plans without Part D coverage typically will not cover prescription colonoscopy prep kits.
Coverage and out-of-pocket costs can vary between plans. Some Medicare Advantage plans may offer more favorable cost-sharing compared with standalone Medicare Part D plans, while others may have different restrictions.
Patients can check their plan’s drug formulary and coverage details through the Medicare Plan Finder tool to determine whether their specific PEG bowel prep kit is covered and what costs may apply.
How much do low-volume PEG preps cost with Medicare?
According to the Colon Cancer Coalition, the cost of colonoscopy preparation can vary significantly depending on the type of bowel prep and a patient’s insurance coverage.
- The median out-of-pocket cost for low-volume bowel preparation kits after Medicare coverage is about $56.
- The average out-of-pocket cost for high-volume bowel preparations is about $8.
These figures are estimates and may not reflect what every patient pays. Actual costs can be higher or lower depending on factors such as:
- The specific Medicare plan
- The prescribed bowel prep product
- Formulary placement
- Copays and deductibles
- Available savings programs
Patients should check their individual Medicare coverage or speak with their healthcare provider to understand the expected cost of their prescribed colonoscopy preparation.
Why Do Medicare Patients Pay More for Low-Volume Preps?
There are several reasons why low-volume bowel preparation kits may cost more than traditional high-volume options.
One major factor is that some Medicare Part D plans place low-volume bowel preps in higher formulary tiers, which can result in higher copays and out-of-pocket costs. Some low-volume preparations also contain additional active ingredients, which may increase manufacturing and development costs. Additionally, certain low-volume bowel preps do not have generic versions available, meaning brand-name products may be the only option.
Unexpected out-of-pocket expenses can affect whether patients complete their recommended preparation. Research suggests that higher medication costs may reduce treatment adherence, which could potentially affect the quality of bowel cleansing before a colonoscopy.
Because of these concerns, medical organizations such as the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy have advocated for reducing cost barriers associated with colonoscopy preparation medications. Some states have also introduced policies requiring health plans to provide coverage for bowel preparation products.
How to Lower the Cost of Colonoscopy Prep With Medicare
If your Medicare plan does not fully cover your prescribed bowel preparation kit, there are several options to consider:
1. Check for lower-cost alternatives covered by your plan
Medicare Part D plans may prefer certain bowel preparation products over others. Ask your healthcare provider whether there are alternative prep options that provide similar results but have lower out-of-pocket costs.
A commonly used alternative is generic PEG-3350 with electrolytes (such as generic GoLYTELY), which may have broader coverage and lower copays compared with some brand-name low-volume preparations.
2. Ask your healthcare provider about a formulary exception
In some situations, a low-volume bowel prep may be medically necessary. For example, patients who have difficulty tolerating large amounts of liquid may benefit from a lower-volume option.
Your healthcare provider may be able to submit documentation to your insurance plan explaining why a specific preparation is appropriate
3. Review your Medicare plan coverage before your procedure
Because coverage varies by plan, reviewing your Part D formulary before filling a prescription can help you understand:
- Which bowel prep options are covered
- Your expected copay
- Whether prior approval is required
- Whether alternative options are available
Source: SingleCare