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 |
|---|---|---|
| Aetna | National | Commercial, Medicare Advantage |
| Anthem Central Region | OH, IN, KY, MO, WI | Commercial, Medicare Advantage |
| Arise Health Plan/WPS Health Insurance | WI | Commercial |
| Aultcare | OH | Commercial, Medicare Advantage |
| Blue Cross and Blue Shield Federal Employees Program | National | |
| Blue Cross Blue Shield of Michigan | MI | Commercial PPO |
| Blue Cross & Blue Shield of Minnesota | MN | Commercial, Medicare Advantage, Managed Medicaid |
| Blue Cross and Blue Shield of Kansas | KS | Commercial |
| Common Ground Healthcare Cooperative | WI | Commercial Envision Network |
| 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 |
| HealthPartners | MN, IA, WI | Commercial, Medicare Advantage, Managed Medicaid |
| Health Tradition Health Plan | WI | Commercial, Managed Medicaid |
| Humana | National | Commercial, Medicare Advantage, Managed Medicaid |
| Medical Mutual of Ohio | OH | Commercial, Medicare Advantage |
| MercyCare Health Plan | WI, IL | Commercial, Managed Medicaid |
| MHS Wisconsin | WI | Commercial, Medicare Advantage |
| Ohio State University Health Plan | OH | Commercial |
| Physicians Plus | WI | Commercial, Managed Medicaid |
| Priority Health | MI | Commercial, Medicare Advantage, Managed Medicaid |
| Quad City Community Healthcare | IA | Commercial |
| Security Health Plan | WI | Commercial, Medicare Advantage, Managed Medicaid |
| United Healthcare | National | Commercial, Medicare Advantage |
| Unity Health Plan | WI | Commercial |
| WEA Trust | WI | Commercial |
| Wellmark Blue Cross and Blue Shield of Iowa | IA | Commercial |
| Wellmark Blue Cross and Blue Shield of South Dakota | SD | 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
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 |
|---|---|---|
| Aetna | National | Commercial, Medicare Advantage |
| Amerihealth New Jersey | NJ | Commercial, Medicare Advantage |
| Blue Cross and Blue Shield Federal Employees Program | National | |
| Blue Cross & Blue Shield of Massachusetts | MA | Commercial, Medicare Advantage |
| Blue Cross & Blue Shield of Rhode Island | RI | Commercial, Medicare Advantage |
| Blue Cross and Blue Shield of Vermont | VT | Commercial, Medicare Advantage |
| Excellus BlueCross BlueShield | NY | Commercial, Medicare Advantage |
| Fallon Community Health Plan | MA | Commercial, Medicare Advantage |
| Geisinger Health Plan | PA | Commercial, Medicare Advantage |
| Harvard Pilgrim Health Plan | MA | Commercial |
| Healthsmart World Trade Center Health Plan | NY | Commercial |
| Highmark Blue Cross and Blue Shield | PA, WV, DE | Commercial, Medicare Advantage |
| Humana | National | Commercial, Medicare Advantage, Managed Medicaid |
| Independent Health Association | NY | Commercial, Medicare Advantage |
| Tufts Health Plan | MA, RI, NH | Commercial, Medicare Advantage, Managed Medicaid |
| United Healthcare | National | Commercial, Medicare Advantage |
| Univera Healthcare | NY | 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
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 |
|---|---|---|
| Aetna | National | Commercial, Medicare Advantage |
| Anthem Blue Cross & Blue Shield of Virginia | VA | Commercial (HMO excluded), Medicare Advantage |
| Blue Cross and Blue Shield Federal Employees Program | National | |
| Highmark Blue Cross and Blue Shield | PA, WV, DE | Commercial, Medicare Advantage |
| Humana | National | Commercial, Medicare Advantage, Managed Medicaid |
| Optima Health | VA | Commercial, Managed Medicaid, Medicare Advantage |
| Sentara Health Plan | VA | Commercial, Managed Medicaid, Medicare Advantage |
| United Healthcare | National | 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
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 |
|---|---|---|
| Aetna | National | Commercial, Medicare Advantage |
| Anthem Blue Cross & Blue Shield of Georgia | GA | Commercial (HMO excluded), Medicare Advantage |
| Blue Cross and Blue Shield Federal Employees Program | National | |
| Blue Cross & Blue Shield of Florida | FL | Commercial, Medicare Advantage |
| Blue Cross & Blue Shield of Louisiana | LA | Commercial, Medicare Advantage |
| Humana | National | Commercial, Medicare Advantage, Managed Medicaid |
| United Healthcare | National | 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
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 |
|---|---|---|
| Aetna | National | Commercial, Medicare Advantage |
| Anthem Blue Cross of California | CA | Commercial (HMO excluded), Medicare Advantage |
| Blue Cross and Blue Shield Federal Employees Program | National | |
| Blue Cross and Blue Shield of Arizona | AZ | Medicare Advantage |
| Culinary Health Fund | NV | Commercial |
| Health Plan of Nevada | NV | Commercial, Medicare Advantage |
| Humana | National | Commercial, Medicare Advantage, Managed Medicaid |
| Moda Health | OR | Commercial |
| Presbyterian Health Plan | NM | Medicare Advantage |
| Providence Health Plan | OR | Medicare Advantage |
| United Healthcare | National | Commercial, Medicare Advantage |
| Sanford Health Plan | SD | Commercial |
IN NETWORK PLANS - MEDICAL GROUPS AND IPAs
| Payor | State |
|---|---|
| Access Medical Group (HMO) | CA |
| Axminster Medical Group | CA |
| Brown and Toland Physicians (HMO) | CA |
| California IPA | CA |
| Community Care IPA | CA |
| Dignity Health Medical Foundation | CA |
| Facey Medical Group (HMO) | CA |
| Medi Choice IPA | CA |
| Meritage Medical Network (HMO) | CA |
| Premier Care IPA | CA |
| SanSum Clinic (HMO) | CA |
| Santa Clara County IPA | 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
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
- Avera Health Plans
- Blue Cross & Blue Shield Federal Employee Program
- Blue Cross & Blue Shield of Illinois
- Blue Cross and Blue Shield of Nebraska
- Blue Cross and Blue Shield of North Dakota
- Cigna
- Government Employees Health Association (GEHA)
- Health Alliance Medical Plan
- Health Alliance Plan
- Medica
- Network Health
- Paramount
- Sanford 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
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 and Blue Shield of Northeastern New York
- Blue Cross & Blue Shield of Western New York
- BMC HealthNet Plan
- Capital BlueCross
- Capital District Physicians Health Plan
- Cigna
- Excellus Blue Cross & Blue Shield
- Government Employees Health Association (GEHA)
- Horizon Blue Cross Blue Shield of New Jersey
- Independence Blue Cross
- MVP Health Plan
- TRICARE
- Well Sense 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
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
- Carefirst Blue Cross & Blue Shield
- Cigna
- Government Employees Health Association (GEHA)
- Johns Hopkins Employee Health Plan
- Piedmont Community 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
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 and Blue Shied of Tennessee
- 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
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 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 & Blue Shield of Wyoming
- Blue Cross of Idaho
- Blue Shield of California
- Bridgespan Health Insurance
- Care n' Care
- Cigna
- El Rio Health
- Government Employees Health Association (GEHA)
- Hawaii Medical Service Association
- Health Choice Oklahoma
- Health Net
- LifeWise Health Plan of Oregon
- LifeWise Health Plan of Washington
- New Mexico Health Connections
- Pacific Source Health Plans
- Premera Blue Cross
- Presbyterian Health Plan
- Providence Health Plan
- Regence Blue Cross & Blue Shield
- Regence Blue Shield
- Rocky Mountain Health Plan
- Seton Health Plan
- Sutter Health Plus
- TRICARE
- University Health Alliance
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