Does Medicare Pay for Low-t Testosterone Treatments?
Medicare Part A and Part B coverage includes benefits for many inpatient and outpatient medically necessary services. But, if your doctor has recommended testosterone treatments, you may be wondering if your benefits will apply. Coverage will likely depend on your personal needs, the reason for treatment, and what benefits you have.
If the low-t hormone therapy is considered medically necessary, then Medicare will most likely help cover the cost. Check your plan benefits to verify coverage as the testosterone therapy may need to be administered by a qualified healthcare professional in a Medicare-certified facility.
What Does Medicare Cover for Testosterone Replacement Therapy?
TRT is a form of hormone replacement therapy (HRT) that delivers testosterone directly into your bloodstream using one of the following methods:
- Skin patch you can apply daily
- Gel applied directly to the skin or nasal cavity or delivered through a pump
- Mouth patch or tablet that adheres to your gums
- Injections into muscles
- Pellets implanted into soft tissues
Hypogonadism (low hormone production) may be the result of chemotherapy, radiation, trauma, human immunodeficiency virus (HIV) and other disorders. TRT coverage is contingent upon the diagnosis of an associated medical condition.
Medicare only covers services and supplies that are deemed medically necessary. So, although medications like Viagra are typically not covered, testosterone and other hormone replacement therapies may be covered.
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Does Medicare Cover Testosterone Therapy?
The Centers for Medicare & Medicaid Services (CMS) determined that testosterone treatment is deemed medically necessary when prescribed for the following conditions:
- Male hypogonadism with symptoms, due to testicle, pituitary gland or brain disorder
- Delay in male puberty
- Gender dysphoria (sense of ill-being, anxiety, discontent or discomfort)
Original Medicare would deny testosterone treatment if you:
- Have hypogonadism caused by aging
- Have been diagnosed with breast cancer
- Had a prostate cancer diagnosis, unless you are disease-free for a minimum of two years following radical surgery to remove the prostate gland
- Are experiencing male menopause
- Are planning to have children
Does Medicare Cover Testosterone Drugs?
To get Medicare benefits for prescription drugs, you have to sign up for Medicare Part D. Prescription drug coverage is optional, but is available in a stand-alone Prescription Drug Plan (PDP) if you have Original Medicare. As an alternative, you may choose to enroll in a Medicare Advantage plan that includes Part A, Part B, and Part D benefits under one plan. Enrollment in Part D is not automatic when you enroll in Part A and Part B.
To check if your Medicare prescription drug plan covers testosterone, search the plan’s formulary (list of covered drugs) under the heading of androgens (steroids that act as the male sex hormone).
The formulary should delineate coverage for injections, gel and topicals. Look for parameters, such as prior authorization (PA), quality limits (QL) and mail order (MO). Keep in mind that when you purchase a brand versus a generic drug, cost-sharing will be higher.
Does Medicare Part B Cover Testosterone Injections?
If you are eligible for testosterone therapy, Medicare Part B may cover drugs you receive as an outpatient. The benefit includes injectable and implantable drugs your provider administers at the doctor’s office.
The Part B benefit also covers some drugs requiring certain types of durable medical equipment. The Part B deductible and a 20% coinsurance payment apply. If you have a Medicare Supplement plan, check your coverage for the Part B coinsurance and copayments.
What are the symptoms of Low T Levels?
According to the Mayo Clinic, symptoms indicative of low testosterone (Low-T) may differ depending on when the condition develops. Hypogonadism could start at any point from the womb through adulthood:
- Fetal development: female, ambiguous or underdeveloped male genitals
- Puberty: Delay in developing muscle mass, deep voice and growth of hair or genitals
- Adulthood: depression, decreasing sex drive, reduced energy, erectile dysfunction, infertility, bone loss or breast development, and in severe cases, difficulty with concentration and hot flashes
If you have symptoms of hypogonadism, your doctor may order a blood test. Medicare covers blood tests and other laboratory services through Part B. Part B also covers diagnostic tests like X-rays, MRIs and CT scans that your doctor may order to investigate underlying medical conditions for Low-T. Your obligation is the Part B deductible and coinsurance payment.
Will Medicare Advantage Cover TRT?
Medicare Advantage (MA), sold by private insurance companies, may offer more benefits than Original Medicare but will not offer less. The policy may have a broader definition of what is considered medically necessary to be eligible for TRT. MA members have access to an Evidence of Coverage document that describes benefit details and exclusions. If you have Medicare Advantage with a prescription drug plan (MAPD), search the plan’s formulary for testosterone prescriptions.
Unlike Original Medicare, Medicare Advantage can require you to use a network healthcare provider to receive full benefits. The plan’s network directory identifies contracted healthcare service providers, including medical teams, hospitals, outpatient facilities and pharmacies. Read your plan’s materials carefully to get the most out of your coverage.
How to Get Medicare Testosterone Coverage
If you are unsure how to get testosterone therapy covered by Medicare, reach out to the billing or insurance specialist in your doctor’s practice who would submit the authorization request to Medicare. You may be able to keep your cost-sharing down if you qualify for Medicaid. You can visit the official government Medicaid website to research the eligibility criteria.
If you’re considering switching plans, start by comparing plans in your area. You may be able to switch plans during Medicare’s annual Open Enrollment Period, from October 15 through December 7. If you’re already enrolled in an MA plan, you can make one change during the Medicare Advantage Open Enrollment Period from January 1- March 31.
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