Does Health Insurance Cover Hormone Therapy?

Health insurance often covers hormone therapy, although it may only cover therapy for specific types of treatment plans and varies between health insurance companies. Ensuring you have coverage is essential to help you get affordable hormone replacement therapy and other treatment types, as some therapy options can cost hundreds of dollars per month or more in prescription costs without health insurance.

Keep reading to learn when health insurance will cover hormone therapy, how much you might pay without coverage and some of the treatment types available.

On This Page

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  What Is Hormone Therapy?

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  What Types of Insurance Cover Hormone Therapy?

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  How Much Does Hormone Therapy Cost Without Insurance?

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  How Do I Know if My Insurance Plan Covers Hormone Therapy?

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  Tips To Get Coverage Approved for Hormone Therapy

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  FAQs

What Is Hormone Therapy?

Hormone therapy is a medical treatment that replaces, alters or blocks hormone production in the body. It’s often utilized in treating various types of cancer, reducing menopause symptoms and providing gender-affirming care. For example:

• Replace hormones: Hormone replacement therapy (HRT) can help replace decreasing estrogen and progesterone levels in someone experiencing menopause, which can help alleviate symptoms like hot flashes, mood swings and vaginal dryness, prevent osteoporosis and reduce the risk of colon cancer.^[1] Bioidentical hormone replacement therapy (BHRT) is a type of therapy that seeks to correct imbalances in hormone production, such as increasing low testosterone levels in men.^[2]
• Alter hormones: Hormone therapy can reduce the amount of naturally produced testosterone, which can be used to treat prostate cancer.^[3]
• Block hormones: Hormone therapy can be used to halt estrogen production in the body, which is used to treat breast cancer by starving the cancer cells of the hormones they use to grow.^[4] Certain types of hormone blockers, called puberty blockers, are utilized in gender-affirming care for transgender individuals to help suppress the production of estrogen or testosterone and reduce the development of associated characteristics during puberty, which may otherwise be more difficult to change if left to develop.^[5][6]

Hormone replacement therapy and other types can come in various forms, such as oral medication, pellets placed under the skin, shots and creams.^[2][7]

What Types of Insurance Cover Hormone Therapy?

Commercial health insurance, whether purchased through the Health Insurance Marketplace or through an employer, may cover hormone therapy, but coverage will likely depend on the specific provider and type of therapy. For example, some insurance companies, such as Kaiser, won’t cover hormone therapy at all. However, most plans will cover hormone replacement therapy when prescribed by a primary care provider, such as treating menopausal symptoms.^[8]

Coverage may be dependent on whether the treatment is FDA-approved. Treatments may also need to be prescribed by a doctor and considered medically necessary. Certain treatment types, such as bioidentical hormone replacement therapy, may be more likely to be covered.^[8]

Additionally, some methods of hormone therapy, such as estrogen pellets, may be considered as an alternative and may be more difficult to get covered, particularly if prescribed out of network.^[8]

Below is a quick breakdown of several different hormone therapy types and whether they’re covered by private health insurance:[8]

Original Medicare doesn’t cover hormone therapy. However, you might be covered for prescription medication costs if you’ve purchased Medicare Advantage or a standalone Medicare Part D, which are additional costs to your existing Medicare premium.^[9]

Medicaid may cover hormone therapy, but it will vary based on state laws and the type of therapy. For example, in Texas, Medicaid coverage excludes hormone therapy when used for gender-affirming care. However, Texas Medicaid may cover hormone therapy for treating menopausal symptoms if given prior authorization by a healthcare provider.^[10][11]

How Much Does Hormone Therapy Cost Without Insurance?

Hormone therapy can cost between $10 to $500 or more per month without insurance, depending on factors such as:^[8]

• The type of therapy, such as hormone replacement therapy, compared to hormone blockers
• The delivery method, such as a cream compared to an injection
• The dosage of medication needed per application
• Whether generic or brand-name drugs are prescribed

For example, hormone replacement therapy for menopause can cost $10 per month for a 90-day supply of generic-brand estrogen oral medication. In contrast, a vaginal ring that releases a low dose of estrogen lasts for 90 days and could cost over $1,000 without insurance.^[12]

How Do I Know if My Insurance Plan Covers Hormone Therapy?

Since hormone therapy coverage varies by insurance provider, health plan and the type of therapy, you’ll need to check your policy details to see if you’re fully or partially covered.

What Should I Do if My Insurance Denies Coverage for Hormone Therapy?

If your coverage is denied for hormone therapy, you may be able to appeal the decision. It may also require you to seek a different healthcare professional if your initial prescription was given out of network. You may also need a specific diagnosis, such as some insurance company plans requiring a gender dysphoria diagnosis to cover hormone replacement therapy for individuals in need of gender-affirming care.^[5]

If your coverage is denied on the basis that your health plan or insurance company doesn’t cover hormone therapy at all, you’ll likely need to pay out of pocket for the prescribed treatment.

It may be worth researching other health care plans or insurance companies that don’t exclude hormone therapy, although you may need to wait until open enrollment to switch plans.

Tips To Get Coverage Approved for Hormone Therapy

Below are a few tips to consider when seeking approval for hormone therapy coverage:

• Work with your primary care provider to get a formal diagnosis for any issue that may be treatable with hormone therapy, if you haven’t already.
• Speak with your insurance company and seek prior authorization, ensuring you keep important documents and previously taken medications to provide if necessary.
• Consider requesting generic FDA-approved medications, which may be more likely to be approved.
• Check the details of your health insurance plan to ensure hormone therapy is covered and how much you’ll be responsible for covering out of pocket.
• Use in-network providers and pharmacies to reduce billing and administrative issues, which also helps reduce your costs.
• Consider shopping around for a different health insurance carrier if your current insurer doesn’t cover hormone therapy or only offers limited coverage that doesn’t meet your needs.