Insurance & Billing

We realize healthcare coverage and reimbursement can be complicated. Cologuard patients with billing questions can call us at 1-844-870-8870.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test.

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

MEDICARE & MEDICARE ADVANTAGE

Federal law guarantees coverage and reimbursement for all Medicare and Medicare Advantage patients who are ages 50-85 and of average risk for colorectal cancer.

Payor State Includes Members with These Types of Plans
Traditional Medicare National 100% covered. $0 co-pays or deductibles
Medicare Advantage * National 100% covered. $0 co-pay or deductible since June 15, 2016

*We highly recommend Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

IN NETWORK PLANS

What does "in network" mean?

For Cologuard, this generally means that Exact Sciences has contracted with the insurer to be part of their preferred lab network, and the insurer will pay all or part of the cost of the test for patients who meet certain clinical criteria.

Insurers have coverage and network limitations and exclusions which may apply. We highly recommend Cologuard patients call their insurer directly to confirm what they will pay, what they expect the patient to pay, and if any paperwork is required before the patient uses the test.

MIDWEST

Even if an insurer covers Cologuard, the deductible, co-pay, or other out-of-pocket costs may vary from $0 to $649 according to the patient’s plan-specific benefits.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

Exact Sciences does not verify insurance coverage or eligibility. 

Payor State Includes Members with These Types of Plans
Anthem Central Region OH, IN, KY, MO, WI Commercial, Medicare Advantage
Arise Health Plan/WPS Health Insurance WI Commercial
Blue Cross & Blue Shield of Minnesota MN Commercial, Medicare Advantage, Managed Medicaid
Dean Health Plan/Prevea360 Health Plan WI Commercial, Medicare Advantage, Managed Medicaid
Group Health Cooperative Eau Claire WI Commercial
Group Health Cooperative of South Central WI WI Commercial HMO
Health Tradition Health Plan WI Commercial, Managed Medicaid
Humana National Commercial, Medicare Advantage, Managed Medicaid
Ohio State University Health Plan OH Commercial
Physicians Plus WI Commercial, Managed Medicaid
Priority Health MI Commercial, Medicare Advantage, Managed Medicaid
Security Health Plan WI Commercial, Medicare Advantage, Managed Medicaid
Unity Health Plan WI Commercial

Note: The above information reflects Exact Sciences’ interpretation of available insurance coverage information as of February 1, 2017. Exact Sciences makes no warranties with respect to this information or coverage decisions related to its use. ©2017 Exact Sciences Corporation. All rights reserved. CG-00410-01

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NORTHEAST

Even if an insurer covers Cologuard, the deductible, co-pay, or other out-of-pocket costs may vary from $0 to $649 according to the patient’s plan-specific benefits.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

Exact Sciences does not verify insurance coverage or eligibility. 

Payor State Includes Members with These Types of Plans
Blue Cross & Blue Shield of Massachusetts MA Commercial, Medicare Advantage
Blue Cross & Blue Shield of Rhode Island RI Commercial, Medicare Advantage
Humana National Commercial, Medicare Advantage, Managed Medicaid
Tufts Health Plan MA, RI, NH Commercial, Medicare Advantage, Managed Medicaid
UPMC PA Commercial and Medicare Advantage

Note: The above information reflects Exact Sciences’ interpretation of available insurance coverage information as of February 1, 2017. Exact Sciences makes no warranties with respect to this information or coverage decisions related to its use. ©2017 Exact Sciences Corporation. All rights reserved. CG-00410-01

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MID-ATLANTIC

Even if an insurer covers Cologuard, the deductible, co-pay, or other out-of-pocket costs may vary from $0 to $649 according to the patient’s plan-specific benefits.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

Exact Sciences does not verify insurance coverage or eligibility.

Payor State Includes Members with These Types of Plans
Anthem Blue Cross & Blue Shield of Virginia VA Commercial (HMO excluded), Medicare Advantage
Carefirst Blue Cross & Blue Shield MD, VA, DC Commercial PPO
Humana National Commercial, Medicare Advantage, Managed Medicaid
Optima Health/Sentara Health Plan VA  Commercial, Medicare Advantage

Note: The above information reflects Exact Sciences’ interpretation of available insurance coverage information as of February 1, 2017. Exact Sciences makes no warranties with respect to this information or coverage decisions related to its use. ©2017 Exact Sciences Corporation. All rights reserved. CG-00410-01

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SOUTH

Even if an insurer covers Cologuard, the deductible, co-pay, or other out-of-pocket costs may vary from $0 to $649 according to the patient’s plan-specific benefits.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

Exact Sciences does not verify insurance coverage or eligibility.

Payor State Includes Members with These Types of Plans
Anthem Blue Cross & Blue Shield of Georgia GA Commercial (HMO excluded), Medicare Advantage
Blue Cross & Blue Shield of Louisiana LA Commercial, Medicare Advantage
Humana National Commercial, Medicare Advantage, Managed Medicaid

Note: The above information reflects Exact Sciences’ interpretation of available insurance coverage information as of February 1, 2017. Exact Sciences makes no warranties with respect to this information or coverage decisions related to its use. ©2017 Exact Sciences Corporation. All rights reserved. CG-00410-01

Close

WEST

Even if an insurer covers Cologuard, the deductible, co-pay, or other out-of-pocket costs may vary from $0 to $649 according to the patient’s plan-specific benefits.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

Exact Sciences does not verify insurance coverage or eligibility.

IN NETWORK PLANS - PRIVATE INSURERS

Payor State Includes Members with These Types of Plans
Anthem Blue Cross of California CA Commercial (HMO excluded), Medicare Advantage
Humana National Commercial, Medicare Advantage, Managed Medicaid

IN NETWORK PLANS - MEDICAL GROUPS AND IPAs

Payor State
Access Medical Group (HMO) CA
Brown and Toland Physicians (HMO) CA
Facey Medical Group (HMO) CA
Meritage Medical Network (HMO) CA
Premier Care IPA CA
SanSum Clinic (HMO) CA
Seoul Medical Group (HMO) CA

Note: The above information reflects Exact Sciences’ interpretation of available insurance coverage information as of February 1, 2017. Exact Sciences makes no warranties with respect to this information or coverage decisions related to its use. ©2017 Exact Sciences Corporation. All rights reserved. CG-00410-01

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PLANS WITH POSITIVE MEDICAL POLICY

What does “positive medical policy” mean?

For Cologuard, this generally means that the insurer considers the test to be eligible for potential coverage and to be medically necessary for patients who meet certain clinical criteria.

However, this does not guarantee the insurer will pay all or part of the cost of the test. Even covered claims may require patient payment of up to $649. Patients should still call their insurer directly to confirm what they will pay, what they expect the patient to pay, and if any paperwork is required before the patient uses the test.

MIDWEST

Even if an insurer covers Cologuard, the deductible, co-pay, or other out-of-pocket costs may vary from $0 to $649 according to the patient’s plan-specific benefits.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

Exact Sciences does not verify insurance coverage or eligibility.

  • Anthem Blue Cross & Blue Shield
  • Blue Cross & Blue Shield Federal Employee Program
  • Blue Cross & Blue Shield of Illinois
  • Cigna
  • Government Employees Health Association (GEHA)
  • Medica
  • Medical Mutual of Ohio
  • TRICARE
  • Wellmark Blue Cross & Blue Shield of Iowa
  • Wellmark Blue Cross & Blue Shield of South Dakota

Note: The above information reflects Exact Sciences’ interpretation of available insurance coverage information as of February 1, 2017. Exact Sciences makes no warranties with respect to this information or coverage decisions related to its use. ©2017 Exact Sciences Corporation. All rights reserved. CG-00410-01

Close

NORTHEAST

Even if an insurer covers Cologuard, the deductible, co-pay, or other out-of-pocket costs may vary from $0 to $649 according to the patient’s plan-specific benefits.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

Exact Sciences does not verify insurance coverage or eligibility.

  • 1199 SEIU
  • Anthem Blue Cross & Blue Shield
  • Blue Cross & Blue Shield Federal Employee Program
  • Blue Cross & Blue Shield of Western New York
  • Cigna
  • Excellus Blue Cross & Blue Shield
  • Fallon Community Health Plan
  • Geisinger Health Plan
  • Government Employees Health Association (GEHA)
  • Highmark Blue Cross & Blue Shield
  • Independence Blue Cross
  • MVP Health Plan
  • TRICARE
  • Univera Healthcare
  • World Trade Center Health Plan

Note: The above information reflects Exact Sciences’ interpretation of available insurance coverage information as of February 1, 2017. Exact Sciences makes no warranties with respect to this information or coverage decisions related to its use. ©2017 Exact Sciences Corporation. All rights reserved. CG-00410-01

Close

MID-ATLANTIC

Even if an insurer covers Cologuard, the deductible, co-pay, or other out-of-pocket costs may vary from $0 to $649 according to the patient’s plan-specific benefits.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

Exact Sciences does not verify insurance coverage or eligibility.

  • Anthem Blue Cross & Blue Shield
  • Blue Cross & Blue Shield Federal Employee Program
  • Cigna
  • Government Employees Health Association (GEHA)
  • Johns Hopkins Employee Health Plan
  • TRICARE

Note: The above information reflects Exact Sciences’ interpretation of available insurance coverage information as of February 1, 2017. Exact Sciences makes no warranties with respect to this information or coverage decisions related to its use. ©2017 Exact Sciences Corporation. All rights reserved. CG-00410-01

Close

SOUTH

Even if an insurer covers Cologuard, the deductible, co-pay, or other out-of-pocket costs may vary from $0 to $649 according to the patient’s plan-specific benefits.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

Exact Sciences does not verify insurance coverage or eligibility.

  • Anthem Blue Cross & Blue Shield
  • AvMed
  • Blue Cross & Blue Shield Federal Employee Program
  • Blue Cross & Blue Shield of Florida
  • Cigna
  • Government Employees Health Association (GEHA)
  • HealthChoice/Orlando Health
  • Rosen Medical Center
  • TRICARE

Note: The above information reflects Exact Sciences’ interpretation of available insurance coverage information as of February 1, 2017. Exact Sciences makes no warranties with respect to this information or coverage decisions related to its use. ©2017 Exact Sciences Corporation. All rights reserved. CG-00410-01

Close

WEST

Even if an insurer covers Cologuard, the deductible, co-pay, or other out-of-pocket costs may vary from $0 to $649 according to the patient’s plan-specific benefits.

We highly recommend that Cologuard patients call their insurer directly to confirm what they will pay, what the insurer expects the patient to pay, and if the patient or prescriber needs to file any paperwork (like a prior authorization) before the patient uses the test. 

When patients call to check with their insurer, please provide this information:

  • Provider of Cologuard is Exact Sciences Laboratories AND
  • Cologuard is billed under CPT code 81528

Exact Sciences does not verify insurance coverage or eligibility.

  • Anthem Blue Cross & Blue Shield
  • Anthem Blue Cross California (PPO)
  • Arizona Health Care Cost Containment System
  • Asuris Northwest Health
  • Blue Cross & Blue Shield Federal Employee Program
  • Blue Cross & Blue Shield of Arizona
  • Blue Cross & Blue Shield of Kansas
  • Blue Cross & Blue Shield of Montana
  • Blue Cross & Blue Shield of New Mexico
  • Blue Cross & Blue Shield of Oklahoma
  • Blue Cross & Blue Shield of Texas
  • Blue Cross of Idaho
  • Bridgespan Health Insurance (OR, WA, UT, ID)
  • Cigna
  • Government Employees Health Association (GEHA)
  • Health Net
  • New Mexico Health Connections
  • Pacific Source Health Plans
  • Providence Health Plan
  • Quad City Community Healthcare
  • Regence Blue Cross & Blue Shield (OR, UT)
  • Regence Blue Shield (WA, ID)
  • Rocky Mountain Health Plan
  • TRICARE

Note: The above information reflects Exact Sciences’ interpretation of available insurance coverage information as of February 1, 2017. Exact Sciences makes no warranties with respect to this information or coverage decisions related to its use. ©2017 Exact Sciences Corporation. All rights reserved. CG-00410-01

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Have questions about insurance or billing? Contact our Patient Support Team at 1-844-870-8870 or view a list of FAQs.
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