Prostate cancer treatment

Prostate cancer treatment includes therapies such as surgery, radiation therapy, hormone therapy, and chemotherapy aimed at eliminating or controlling prostate tumors. Insurance typically covers procedures like radical prostatectomy, intensity-modulated radiation therapy (IMRT), and androgen deprivation therapy when deemed medically necessary.

Most health insurance plans require pre-authorization for expensive treatments like robotic-assisted laparoscopic prostatectomy. Out-of-pocket costs for insured patients often range from $3,000 to $8,000 for surgery, depending on deductibles and coinsurance rates.

Medicare Part B covers physician-administered drugs and outpatient treatments, including Lupron injections, but beneficiaries usually pay 20% of the Medicare-approved amount after meeting the Part B deductible ($240 in 2024). Marketplace plans cover FDA-approved oral medications like abiraterone (Zytiga) and enzalutamide (Xtandi), subject to plan formularies and tier levels.

Medicaid covers prostate cancer treatments listed as essential health benefits in all 50 states; for example, California’s Medi-Cal program pays for proton beam therapy if supported by clinical guidelines. Secondary insurance policies, such as Medigap Plan G, often cover most remaining out-of-pocket expenses not paid by Original Medicare for approved prostate cancer therapies.

Insurers deny experimental treatments–like high-intensity focused ultrasound (HIFU)–unless backed by robust clinical trial data or inclusion in medical policy bulletins. Appeals processes allow patients to challenge denials using documentation from board-certified oncologists and peer-reviewed studies supporting clinical efficacy, according to YourInsurance.info.

Major private insurers–UnitedHealthcare, Anthem Blue Cross Blue Shield, Aetna–list covered prostate cancer interventions in publicly available documents called Evidence of Coverage or Summary of Benefits handbooks.