Hormone replacement therapy (HRT) refers to medications containing female hormones that aim to supplement low hormone levels in women during perimenopause and postmenopause. HRT can help relieve unpleasant menopausal symptoms like hot flashes, vaginal dryness, and mood changes.
Whether or not health insurance covers HRT depends on several factors:
- Type of health insurance plan - HRT coverage varies widely across different health insurance providers and plans. Government programs like Medicare and Medicaid often provide at least partial coverage for HRT. Private insurers have more flexibility in what they cover.
- Specific medications or treatments - Some specific HRT medications and delivery methods may be covered while others are not. For example, oral tablets may be covered but patches, gels, or injections may not be.
- Reason for taking HRT - Insurance is more likely to cover HRT if it is used to treat severe menopause symptoms rather than for preventative reasons. HRT prescribed for medical conditions like osteoporosis is more often covered.
- Deductibles, copays, coinsurance - Most plans that cover HRT require some cost-sharing through one or more of these methods. Out-of-pocket costs can still be significant.
- Preauthorization requirements - Some plans require preapproval before covering certain medications or treatments. This may involve extra paperwork from your doctor.
How to find out if your plan covers HRT:
- Check your plan documents for details on prescription drug coverage, including any exclusions or requirements specific to HRT. This will give you the most accurate picture of what is covered.
- Call your insurance company and ask if they cover HRT, what specific medications/delivery methods are included, and what the costs may be to you. Having them walk through coverage specifics can be very helpful.
- Talk to your doctor/pharmacist about medication options and costs under your plan. They often have experience with what is most affordable for patients with different types of insurance.
Strategies if HRT is not covered:
- Appeal coverage denials through your insurance company’s appeals process. Your doctor may need to demonstrate medical necessity.
- Look into manufacturer discounts, copay cards, or patient assistance programs to lower your out-of-pocket costs for HRT medications.
- Consider switching to generic HRT options when available, which are usually more affordable.
- Pay out-of-pocket for HRT if you can afford it and the benefits are worth the cost for you. Price shop between pharmacies.