Will Insurance Cover My Hormone Replacement Therapy?


The short answer is: It depends.

While it may not seem right or fair, the hard truth is that many insurance companies do not look upon hormone therapy as being medically necessary. Instead, they classify it as being an “elective” treatment, and therefore not covered.

The reality is that the insurance industry, large healthcare systems, and big pharma are primarily focused on treating disease after it has already happened, rather than being focused on preventing illness in the first place. Hormone therapy, meanwhile, falls within the preventative medicine category—an arena that the insurance industry generally avoids.

When Hormone Therapy Is Covered By Insurance: Incomplete and/or Outdated Protocols

Have you been told by your insurance company that your policy will cover hormone therapy? You may want to look a little closer. Even when insurance companies say hormone therapy is a covered treatment, the devil is in the details.

Too often the hormone therapy that will be covered consists of partial protocols (e.g. a male patient may find that he can get coverage for some of his testosterone, but no coverage for his estrogen blocker), or protocols that are outdated (e.g. a female patient may find she can get coverage for synthetic estrogen or progesterone, but can’t get coverage for bioidentical hormones).

Dosing can be problematic, too. Frequently insurance companies will only cover the smallest doses necessary to get a patient into the lower threshold of lab tested ranges, rather than being focused on what’s optimal for the patient’s health and wellbeing. In other words, some form of hormone therapy may be covered by your insurance company, but will your hormone levels be optimized?

Compounded medications can present another obstacle to insurance coverage, primarily because the vast majority of insurance companies will not cover medications that are provided by a compounding pharmacy. And yet, compounded medications are necessary if hormone therapy is being done correctly. When medications are compounded, they are custom made on a patient-by-patient basis. This enables physicians to finely tune dosing to each patient’s unique needs. The hormones that may be covered by insurance, on the other hand, are likely to be prescribed on a one-size-fits-all basis. The chances that the perfect dose for you is available “off the shelf” are slim.

Bait and Switch: Buyer Beware

So… let’s say you’ve found a hormone doctor who assures you that your insurance will cover your treatment, and they say they’ll process the claim for you. You may want to verify this with your insurance company directly. Unfortunately, some providers will use this tactic as a way to get you in the door, only to let you know later what they likely knew all along—that your insurance isn’t going to cover the treatment that you need and want.

Don’t Let Insurance Drive Your Decision

We strongly encourage prospective clients to set the insurance dilemma aside when selecting a provider. If the treatment you’re seeking is based on current best practice and is customized to your needs, there’s a better than good chance that all or most of your costs will not be covered by insurance. That being the case, why let insurance be a factor in your decision?

Instead, focus on finding a provider who’s a good fit for you relative to your treatment goals. How is that accomplished? Our advice is to ask lots of questions. If you’re speaking with a prospective provider who either can’t answer your questions, or won’t take the time to do so, that should be a red flag. Move on and find someone else.

The Take Away

Out-of-pocket healthcare expenses can be difficult to accept when most people invest significant sums each month on health insurance premiums. And yet… those who want to focus on prevention may have to do just that. We encourage our clients to compartmentalize the way they approach their healthcare dollars this way:

Use your insurance and its associated providers for day-to-day healthcare needs like a sinus infection or a skin rash, and for the things you hope never happen, like appendicitis or a broken arm.

Meanwhile, most people will have to budget separately for more cutting-edge preventative therapies, particularly those related to healthy aging.

Questions? Renew Youth Has Answers

Let’s chat. Give us a call and tell us about your symptoms, your concerns, and your treatment goals. We’ll happily do our best to answer your questions for you. We can be reached at 800-859-7511.