Does Medicare cover HRT?

Hormone replacement therapy (HRT) is a treatment that your doctor can prescribe for many health problems. It’s often used to help balance progesterone and estrogen levels during or near menopause. Menopause typically begins between ages 45 and 55 and can last seven to 14 years. Many people age into Medicare at 65 years old, so Medicare beneficiaries may be wondering what type of HRT or menopause treatments are covered.

HRT, also known as menopausal hormone therapy, can bring great relief to someone who has hot flashes, excessive sweating, and many other symptoms of menopause. However, you might be surprised to find that it can also reduce the risk of osteoporosis.

 Some types of HRT have both estrogen and progesterone, while others will only have estrogen. In addition, some also contain testosterone. The right combination and dosage of these hormones will depend on why it’s being prescribed as a form of treatment.

Types of hormone replacement therapy

When women go through menopause, they experience hormonal imbalances. Hormone replacement therapy focuses on replacing estrogen in the body that you don’t have after menopause. 

There are two main types:

• Systemic hormone therapy drugs, which come in pill form, ring, gel, skin patch, and spray. These drugs contain a higher dose of estrogen.
• Low-dose vaginal products, which come in cream, ring, or tablet form. These low-dose vaginal preparations are used to treat the vaginal and urinary symptoms of menopause.

Topical creams, like estrogen creams, are used to treat vaginal dryness. While oral medications are usually prescribed for hot flashes.

There are two types of standardized hormone therapy:

1. Estrogen therapy-only therapy (ET): By taking estrogen, women will find relief from many harsh menopausal symptoms. ET is most used for women who had a hysterectomy. 
2. Estrogen plus progesterone therapy (EPT): With EPT, you’re taking both estrogens along with progesterone hormones. Progesterone can protect women from endometrial cancer.

Does Medicare cover hormone replacement therapy?

Medicare Part A coverage:

Part A is your hospital or inpatient coverage. Part A will not cover components of HRT unless inpatient care is required.

Medicare Part B coverage:

• Any diagnostic testing
• Lab work associated with hormone replacement therapy
• Doctor visits for diagnosis and to monitor your response to hormones

Medicare Advantage plans (Part C) or Original Medicare with Medicare Part D coverage:

In order to have HRT prescriptions covered, you’ll need to enroll in either a Medicare Advantage plan with prescription drug coverage or Original Medicare with a stand-alone Part D prescription drug plan that includes HRT drugs on the formulary. Some medications for HRT that may be covered under a MAPD or Part D plan include:

• Estrogen (Estraderm, Premarin, Cenestin, Divigel, and Climara)
• Progestin (Prometrium or Provera)
• Estrogen plus progestin (Prempro, Activella, Femhrt, and Climara Pro)

Hormone replacement therapy for transgender people

Medicare will cover HRT for transgender beneficiaries the same way it would for any other beneficiary. Medicare covers preventive care, medically necessary hormone therapy, and medically necessary transition-related surgery.

What happens if I am denied Medicare coverage?

If you are denied insurance coverage for HRT, and your healthcare provider believes that it’s a medically necessary treatment, you can appeal Medicare’s decision. The Part D appeals process starts with an exception request, and if the request is denied, a formal appeal can be filed.

An authorized representative can also file an appeal on your behalf. You can use your healthcare provider as the authorized representative. You would just need to complete the Appointment of Representative form along with your Redetermination Request form.

Does Medicare pay for hormone replacement therapy?

How much hormone replacement therapy costs under Medicare really depends on the parts of Medicare you’re enrolled in.

Medicare Part B costs:

If you are enrolled in Original Medicare, any outpatient services received while at the doctor’s office, including diagnostic testing, will be covered at 80%. You’ll be responsible for the remaining 20% as well as the Part B deductible. If you have a Medicare supplemental plan (Medigap), you’ll probably have the 20% coinsurance covered. Depending on what letter Medigap plan you have, your Part B deductible may also be covered.

Medicare Advantage plans (Part C) or Medicare Part D costs:

Since Medicare Advantage plans (Part C) are not standardized by the federal government, you’ll need to contact your insurance company directly to find out what your out-of-pocket costs will be. These plans must cover the same services as Original Medicare. However, they can decide what your out-of-pocket costs will be.

The Centers for Medicare & Medicaid Services (CMS) created an online tool that allows you to compare all Part D and Medicare Advantage plans that are available in your area side by side. You just enter your zip code, prescriptions, and pharmacy of choice. This will give you a breakdown of the plan and all the out-of-pocket costs you can expect. Always pay close attention to the plan’s formulary.

Typical costs of hormone replacement therapy

Below are the typical costs of hormone replacement therapy.

• The monthly cost of hormone replacement therapy without insurance can range between $102 and $425 or more, depending on what drugs are prescribed. Generic prescriptions will typically cost less.
• Medicare beneficiaries enrolled in a drug plan or Part C plan with drug coverage can expect prescription drug copays to range from approximately $5 to $30 a month.

Other ways to save on HRT

One of the ways in which you can save on hormone replacement therapy is to have your healthcare provider prescribe generic drugs instead of name-brand drugs as they are typically cheaper.

1. SingleCare coupons

SingleCare has free coupons available that will help you to save on thousands of prescriptions. A SingleCare discount card can help you save 80% on prescriptions, including bioidentical hormones used in HRT.

Prescription drug prices often change. These are the most accurate medication prices at the time of publishing. Click the link under “Savings options” to see updated drug prices.

2. Ask the pharmacy about pricing

Sometimes, the out-of-pocket price for uninsured patients is lower than your insurance or Medicare copay. It’s important to always ask the pharmacist to compare the cash price of a prescription without insurance to your Medicare copay. 

Apply a SingleCare coupon on top of the cash price for an even better discount. Note: Prescriptions paid for out-of-pocket with a SingleCare coupon will not count toward your Medicare deductible.

RELATED: Can I use SingleCare if I’m on Medicare?

3. Extra Help

Those who qualify for Medicare Extra Help will only pay up to $11.20 for brand-name medications and up to $4.50 for generic medications, including HRT medications. The Extra Help program is available to those on Medicare who have limited income and resources.

4. HRT Access Funds

There are programs such as Plume’s HRT Access Funds that will help you with 12 months of free medical care for hormone replacement therapy. Recipients will receive 12 months of:

• 3x year lab work through Quest Diagnostics
• Virtual medical care through telemedicine visits
• 24/7 access to hormone replacement therapy care team
• Prescription cost coverage

There are many benefits to getting hormone replacement therapy that will help you get through menopause and other health situations without too much distress. Speak to your healthcare provider about the options available to you to make the most of your situation.