Does Medicare Cover Zytiga? 

Prostate health is something all men have to take seriously as they age. Among other things, the prostate is responsible for producing seminal fluid to move sperm along during ejaculation. The prostate also surrounds the urethra, which is the tubular structure through which urine is passed from the bladder.

Over time, the prostate naturally enlarges. In fact, there are two distinct growth periods of prostate enlargement in a man’s life; in his teens as hormones fuel growth and then again in his thirties. This growth then continues at a slower rate into a man’s senior years.

The consequences of an enlarged prostate

An enlarged prostate may not cause any symptoms and may not be a cause for concern; however, some men experience urinary problems due to an enlarged prostate placing pressure on the urethra. This can lead to difficulty with urination, frequent and urgent urination and general discomfort.

Additionally, sexual health problems may arise from having an enlarged prostate. In some cases, an enlarged prostate is referred to as benign prostatic hyperplasia (BPH). In other cases, an enlarged prostate and prostate health problems may be the result of prostate cancer.

What causes prostate cancer?

Medical experts are still unsure of the causes of prostate cancer, but men become more susceptible to developing prostate cancer with age. According to the American Cancer Society, around one in eight men will be diagnosed with prostate cancer in their lifetime.

Although prostate cancer is treatable when caught early, the level of treatment will depend on the severity of the case. In extreme cases, surgical removal of the prostate gland may be necessary to eradicate cancer. In others, medications like Zytiga (abiraterone acetate) may be used alongside steroids to administer treatment.

What is Zytiga?

Zytiga is a prescription medication that works by disrupting androgen production. It’s this mechanism that stops feeding tumor growth.

Androgen is a hormone that is produced in the testes and adrenal glands, but prostate cancer tumors are fueled by androgen. When used in conjunction with prednisone, a prescription steroid, Zytiga has been shown to diminish tumor growth in cases of prostate cancer.

Does Medicare cover Zytiga?

Because prostate cancer is a larger concern for men in their senior years, discovering whether Medicare covers Zytiga makes sense. Most commonly, Zytiga is covered by Medicare benefits through Medicare Part D, the prescription drug portion of the program. Each Medicare Part D plan includes a formulary that will tell you what drugs are covered and to what degree. Most Medicare coverage plans under Part D include Zytiga, but you will want to consult your specific formulary to see if there are restrictions or limitations on coverage. As with all items covered under Medicare Part D, you will need to be able to purchase prescriptions from a retail pharmacy in order to use Medicare benefits to pay for prescription drugs.

Medicare will cover Zytiga if it is administered in a hospital or skilled nursing facility during an inpatient stay through Medicare Part A. Medicare recipients receive a limited amount of days per benefit period that are covered at 100% under Medicare Part A.

Medicare coverage for prostate cancer

Overall, Medicare coverage is available for prostate cancer treatment through Medicare Part B, the outpatient benefit. Visits with your doctor or oncologist are covered at a rate of 80%, and Medicare recipients pick up the remaining 20% of outpatient costs under Medicare Part B.

Diagnostic testing to check for prostate cancer and monitor the progression of known prostate cancer is also covered under Medicare Part B. Men over 50 are able to receive one fully-covered digital prostate exam and blood test to check for prostate cancer once every 12 months as well.