Change in T Ranges: How To Handle Insurance?

[tomtom58]

I've been on TRT for just over a year. My last "natural" T level was 284. My Rx goes through a pharmacy benefits manager, and, before it would approve the Rx, it required evidence that I was hypogonadal. Easily done, and the Rx was approved. That approval is up for reexamination in July of this year. Apparently I will no longer be considered hypogonadal and I fear that my Rx will no longer be approved. My urologist thinks there is value in boosting my T and would be happy to renew my Rx, but I'm concerned that the pharmacy benefits manager will bounce it, based solely on the revised T reference standards. Any advice? Is Clomid the alternative?

 

[CoastWatcher]

I've been on TRT for just over a year. My last "natural" T level was 284. My Rx goes through a pharmacy benefits manager, and, before it would approve the Rx, it required evidence that I was hypogonadal. Easily done, and the Rx was approved. That approval is up for reexamination in July of this year. Apparently I will no longer be considered hypogonadal and I fear that my Rx will no longer be approved. My urologist thinks there is value in boosting my T and would be happy to renew my Rx, but I'm concerned that the pharmacy benefits manager will bounce it, based solely on the revised T reference standards. Any advice? Is Clomid the alternative?

How much does your testosterone cost? Enough that it would require you to abandon treatment? You are injecting or using topicals?

 

[Vince Carter]

ya how much are you paying insurance/copay/deductible etc etc

 

[tomtom58]

I started with AndroGel but quit because, at $1K/mo., it was going to run through the Medicare coverage range very quickly. I've been doing injectable for the last 9 months. Cost is only $40/mo. My Medicare supplement doesn't pay anything. I'm assuming it has to go through the pharmacy benefits manager because of the requirement of the Androgen and Anabolic Steroids Act that users not have prostate cancer and be hypogonadic, but maybe I'm wrong about that. If it doesn't have to go through the PBM, then I'm confident that my doc will want me to continue on T.

History: I had prostate cancer, which I have beat. I've been cancer-free for 3+ years, and my PSA is currently 0.32. My doc and I are aware of a survey of medical records done a couple of years ago that showed that men who were treated for prostate cancer with hormone suppression (at one point my T measured 22!) and whose T didn't return to normal levels after cessation of T suppression were 88% more likely to develop Alzheimer's within 3 years. That's scary stuff! I'm 78, I know what T suppression feels like, and I don't want to go back to feeling shitty.

I'm not sure that my doc knows what the protocol is once he puts the Rx into the pharmacy--maybe I need to ask the pharmacy whether the Rx has to go to the PBM, since insurance isn't paying for it.

I'm seeing my doc 7/5 and want to acquire as much information as I can before then.

 

[johndoesmith]

I don't see how this matters to you since you're already on TRT.

If you're on TRT, you will not test hypogonadal, so what's this have to do with your insurance?

Unless your insurance requires you to come off then retest. In that case they're stupid because stopping TRT will make any one seem hypogonadal.

 

[tomtom58]

The issue is that my last "natural" reading was 288. That was hypogonadal then but it isn't now. My concern is that they will look at it again and say no. Their approval was only for a year, so reexamination might be in the cards.

 

[AbsoluteZ3R0]

The issue is that my last "natural" reading was 288. That was hypogonadal then but it isn't now. My concern is that they will look at it again and say no. Their approval was only for a year, so reexamination might be in the cards.

Once you're on trt, it is understood that it is a life-long treatment. They can't use your initial bloodwork as a frame of reference because if you were to come off you'd probably be <100 after a few weeks. I'm assuming you're not at risk of losing your treatment but I could be wrong. Logically it wouldn't make any sense for them to refer to your initial blood work. It could be a problem if you were trying to initiate trt for the first time.

 

[tomtom58]

Once you're on trt, it is understood that it is a life-long treatment. They can't use your initial bloodwork as a frame of reference because if you were to come off you'd probably be <100 after a few weeks. I'm assuming you're not at risk of losing your treatment but I could be wrong. Logically it wouldn't make any sense for them to refer to your initial blood work. It could be a problem if you were trying to initiate trt for the first time.

That's my assumption (and hope) as well. I'm just trying to cover the bases before visiting my doc next week. My prescription is due for renewal on Monday, so I'll use that opportunity to talk to the pharmacist, too.

 

[johndoesmith]

The issue is that my last "natural" reading was 288. That was hypogonadal then but it isn't now. My concern is that they will look at it again and say no. Their approval was only for a year, so reexamination might be in the cards.

Oh I see your concern now.

Honestly, if that ACTUALLY happened, I would be livid. The whole idea that this is even a concern is ridiculous. Seriously, this is just a game of moving the goal posts. Labcorp essentially admitted that this has no clinical or medical justification, yet this will be impacting many many men.

The one thing they never explained, is how is this going to BENEFIT men?

EDIT: I thought of how it will benefit men! Now, there will be a bunch of men who on the night of July 16th will be cured of hypogonadism!!! Labcorp found an overnight cure!! /s

 

[kjcmjc]

Do not use your insurance to get your script filled. I am sure your Dr will write a script. Use GoodRX to get it filled. You avoid the insurance company. My insurance will only cover 1ml prefilled syringes. I get a 10ml vial 200mg for $52.00 at Rite Aid with the Good RX coupon. CVS has it for $48 in my area. Walgreen's around my area will not use the coupon because its a controlled drug. But CVS and Rite Aid will. Look up prices on GoodRX.com and see what it will cost you. Then call those pharmacy's and see if they will honor the coupon. Mine is a lot less than $40.00 a month. I use 120mg a week and that vial lasts me more than 3 months.

 

[Henry]

EDIT: I thought of how it will benefit men! Now, there will be a bunch of men who on the night of July 16th will be cured of hypogonadism!!! Labcorp found an overnight cure!! /s

LMAO!!! To be honest, I'm kind of worried too. Every year, my doc has to send in a form to BC/BS and they authorize my treatment for another year. I was 290 and 277 on 2 early morning tests at Labcorp three years ago. Now, I'm wondering if they'll request that I get off testosterone for 6 weeks to get a baseline again.

The reason why i mentioned baseline is because I actually had a doctor wanting me to do that so he could treat me. He wanted to make sure I was really hypogonadal so he wanted me off test so he could check me again, even though I had 2 early morning Labcorp tests and was on TRT for over a year. I hope the insurance company doesn't try that

 

[Re-Ride]

... Logically it wouldn't make any sense...

Logic has nothing to do with the broken health care / insurance / Big Pharma complex folks. $1,000/month for medicine that cost pennies to make says it all. GREED. Simple arithmetic. It's imploding all around us yet we don't have the backbone to say enough is enough.

...

Honestly... ridiculous...

EDIT: I thought of how it will benefit men! Now, there will be a bunch of men who on the night of July 16th will be cured of hypogonadism!!! Labcorp found an overnight cure!! /s

Our fellow consumers will do nothing until it happens to them. I'm already out. The "insurance" exists on paper only. The "health care" has become even a bigger joke. I can't even get labs anymore. The doc enters them electronically and they disappear in to cyberspace. Fax them in and they "never got them". Hand them a hard copy and they still can't follow doctor's orders.

Something that has worked in the past:

- National day or month of boycott. Don't fill any Rx, don't go to appointments, jam their phone lines with complaints

Start figuring out now how you are going to get by without buying anything from these crooks. The discussion can not be only about insurance premiums. It has to be also about running the pharma cartels out on a rail just as the Rail Barons were run out over a century ago. End graft, send the evil monkeys posing as representatives packing. Finally, introduce QC and efficiency to healthcare with big fines for non-compliance. Currently providers iperate in a vacuum of oversight sans the other criminal gangs we call lawyers. Put down your Eye phones far a night , try to find a place where you can see the stars , gaze upon the Galaxy and contemplate why your country is falling apart around you. Look at he problem not the symptoms. OP if you don't speak Russian or Chinese find someone who does and they will help you get your medicine.

 

[tomtom58]

OK, back to my original question. If I can't get my Rx filled because LabCorp moved the goal posts, is Clomid a viable alternative. It's not a controlled substance. My BC/BS formulary doesn't include it. It would be a simple matter of submitting the Rx to my pharmacy (or some other pharmacy) and getting it filled. No insurance. No hassle. The question is what results can I expect. My last test (last week) my T was 969. Can I get anywhere close to that with Clomid?

 

[johndoesmith]

OK, back to my original question. If I can't get my Rx filled because LabCorp moved the goal posts, is Clomid a viable alternative. It's not a controlled substance. My BC/BS formulary doesn't include it. It would be a simple matter of submitting the Rx to my pharmacy (or some other pharmacy) and getting it filled. No insurance. No hassle. The question is what results can I expect. My last test (last week) my T was 969. Can I get anywhere close to that with Clomid?

You're missing the point. You've already established that you're hypogonadal. How is it that your insurance company will requalify you as hypogonadal?

The only way is to come off TRT to re test. That's it. Once you're on TRT you should not be testing as hypogonadal, or if you are, get a new doctor.

So you're worrying about nothing.

You can always pay cash, no need to come off a protocol that's working and begin a protocol that might not to save $40...

 

[Vince Carter]

OK, back to my original question. If I can't get my Rx filled because LabCorp moved the goal posts, is Clomid a viable alternative. It's not a controlled substance. My BC/BS formulary doesn't include it. It would be a simple matter of submitting the Rx to my pharmacy (or some other pharmacy) and getting it filled. No insurance. No hassle. The question is what results can I expect. My last test (last week) my T was 969. Can I get anywhere close to that with Clomid?

Clomid really has a low success rate, tends to really screw up with Estrogen but it could be something to try. that or HCG, which you can buy overseas w/o script, many guys do that to get it. Clomid, and Anastrozole are available as "research chemicals" which a lot of guys use. So with some out of pocket you can obtain these things. But if your fixated on insurance/medicare/etc, this get's to be really frustrating endeavour. I ditched trying to muck around with my private insurance on meds and labs, at least the way I was doing it, and just pay OOP which Im fortunate to be able to do.

 

[AbsoluteZ3R0]

Seriously, don't bother with clomid after having been on testosterone for a whole year. Clomid is a decent option in men with functioning HTPA/Leydig cells but at this point yours has been shut down for long enough that clomid would either do almost nothing or take months before it "kind of" starts to work. At your age, there's no reason to come off of testosterone. The worst case scenario is that if you're forced off, you can retest after a month or so from your last injection. When you come in at 60ng/dL you will classify as hypogonadal again. Nonetheless, it is a frustrating situation you're in. Hopefully nothing will change.

 

[tomtom58]

I'm not fixated on dealing with the insurance. My BC/BS has reclassified T so that I now pay the full cost. So why bother with putting it through insurance? Clomid isn't in the BC/BS formulary at all--no surprise, since this is a Medicare supplement and Clomid is a fertility treatment and I guess seniors don't need fertility treatment. So, with either one, it's out-of-pocket. T is $40/mo at CVS. I haven't nailed down a price for Clomid, but it took a cursory look and it looked doable.

 

[tomtom58]

Thanks for that. That's the best rationale I've heard (so far).

 

[user_joe]

Find a way to stock up before you hit a wall. Maybe your doc will understand and prescribe extra next go around. You are going to hate life if you needed trt and go off.

 

[Vince Carter]

A Dr that prescribes "extra" of a controlled drug isn't going to have his medical license for very long