Whenever someone is considering a medication, two thoughts are likely to cross their mind: Is this right for me? And does my insurance plan cover it? If you are going through menopause, that may mean asking your doctor those questions about hormone replacement therapy (HRT) — also called menopausal hormone therapy (MHT). The prescription medication boosts your diminishing levels of estrogen and progesterone to relieve menopause symptoms such as hot flashes, irregular bleeding, and vaginal and urinary symptoms. But is HRT covered by insurance? Read on to find out more about the likelihood of insurance covering this treatment, what factors go into it, and how to find out the answer for yourself.
Does insurance cover HRT?
There are no national rules that mandate comprehensive insurance coverage for HRT (though many states are considering bills that would guarantee at least some covered treatments). Despite these holes in care, there are likely some options for you under your insurance. “Every insurance is different, but generally HRT is covered,” says Dr. Deena Adimoolam, M.D., a specialist in endocrinology, diabetes and metabolism based in New Jersey.
That doesn’t mean that any hormone therapy you choose will automatically be included. Coverage will depend on things like the brand name or generic drug prescribed and your specific insurance plan. That said, in the experience of our experts, including Adimoolam and Dr. Taraneh Shirazian, M.D., a gynecologist based in New York City, many of their patients are able to find FDA-approved estrogen and progesterone treatments in some form covered by their insurance.
Does Medicare cover HRT?
Medicare Part D is the part of the national insurance program that offers prescription drug coverage for older people and some people with disabilities. There are many different options available for Part D plans, each with its own list of covered drugs, called a formulary. Look at the formulary on your plan to learn about your options for hormonal treatment.
Does Medicaid cover HRT?
Medicaid, the program for certain people with limited income or resources, has a prescription drug program. Coverage is provided by individual states, so it’s up to your state whether or not HRT is included. Each program has a “preferred drug list” that details which medications are covered, including those offered for menopause treatment. For example, in Illinois, Medicaid’s preferred drug list includes the estrogens premarin and estradiol.
Does Blue Cross Blue Shield cover HRT?
Prescription coverage varies depending on your Blue Cross Blue Shield plan. You can look at your plan’s prescription drug list by logging into your member account and using their search tool.
Does Aetna cover HRT?
Aetna plans may cover menopause treatment, but without knowing your specific plan, it’s impossible to say if your benefits include the specific HRT you’re looking for. Aetna encourages members to search for prescription coverage by logging into their member website.
How much does HRT cost with insurance?
Like all prescription drugs covered by insurance plans, pricing is variable. It will depend on factors like if you’re prescribed brand name or generic, what type of HRT it is (pill vs. patch vs. other form), dose, what pharmacy is filling the prescription, and if you’re using discount programs. One study found that the cost of these medications can range from $10 per month to $700 — a huge range.
Factors affecting insurance coverage for HRT
Everyone’s insurance is different in terms of what is covered and what isn’t. To understand your coverage rules, including co-pays and deductibles that affect your out-of-pocket costs, refer to your specific plan or reach out to customer service using the number on your membership card. Here are a few factors that may come into play:
Medical necessity
Your provider will need to state the reason for the prescription, which is based on their evaluation of your symptoms and health history. (Lab testing is not a reliable way to identify perimenopause, and menopause is diagnosed based on the absence of a menstrual period for 12 consecutive months.) “The diagnosis of menopause or menopausal syndrome (a term for the collection of symptoms that occur during menopause) should be adequate,” says Adimoolam.
Type of HRT
There’s not just one type of hormone therapy. Depending on your symptoms, preferences, and health history, you may be prescribed:
- Systemic therapy: These are medications that enter the bloodstream to treat symptoms like hot flashes. They are available in pills, patches, sprays, and gels.
- Vaginal estrogen therapy: These medications go directly into the vagina to treat vaginal and urinary symptoms. They are available as tablets, inserts, and creams.
The type you’re prescribed may impact insurance coverage. “Certain forms of HRT might have different costs and coverage than others,” says Adimoolam, who has found oral pills to be more likely to be covered. “They are the least expensive, widely available, and [have] many generic options,” she says. In addition, Shirazian adds that, in her experience, the estrogen patch tends to be covered under almost all insurance plans, as well as hormonal IUDs (intrauterine device), which can also be used as part of menopause care.
Each insurer will also have its own rules on coverage for brand name versus generic medications, which will also affect the cost of these medications. Generic medications, when available, are often substantially cheaper than brand name. For example, a combination brand name estrogen/progesterone oral tablet could cost $300 monthly versus $30 for generic.
Pharmacy choice
Some companies or providers use a compounding pharmacy, which creates custom medications individualized for a patient. Compounded medications are often not covered by insurance, unless there is no suitable alternative. Rules differ by insurance, and you may be responsible for a co-pay, so check with your plan.
The bottom line
Insurance generally covers some form of HRT, though it won’t cover every product and formulation. Factors that affect coverage depend on if you’re seeking a brand name drug versus generic, the form of HRT, and the dose. Cost of menopause treatment also depends on if your provider takes insurance or they are self-pay, as well as the pharmacy you get your Rx filled at.
FAQs
A medical provider, such as a gynecologist, primary care provider, or endocrinologist, would diagnose you with menopause or menopausal syndrome (the collection of symptoms of menopause), which is typically enough to qualify for insurance coverage for HRT.
While nobody is ineligible for HRT, you should think about whether or not it’s safe for you. People who should avoid hormone therapy include those who have breast or uterine cancer, unexplained uterine bleeding, liver disease, a history of blood clots, and cardiovascular disease.
If you have bothersome symptoms of menopause that are affecting your quality of life, such as hot flashes, night sweats, mood changes, vaginal dryness, and low libido, you may benefit from talking to your provider about if you’re a good candidate for menopause hormone therapy.
This content is for informational purposes only and does not constitute medical advice, diagnosis or treatment. It should not be regarded as a substitute for guidance from your healthcare provider.