Tips for insurance coverage of TRT and ED meds

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phalloguy100

Active Member
I see a lot of posts here from U.S. users stating that “insurance does not pay” for hCG, FSH, Trimix, and even some testosterone products. Although that may be true of some health plans, I have found that coverage is often permitted via prior authorizations and paying close attention to formularies. I compiled a few tips for getting insurance coverage that I’ve learned over the years. I hope this helps.

1) Peruse the Formulary. Each drug plan has a list of covered drugs and specifically excluded drugs called a formulary. Request it from your insurance company or HR department, and find the coverage limitations for your prescription. Look at Quantity Limit (e.g. only 6 vials or autoinjectors of alpostradil (Caverject/Edex) for ED per month, or 15 vials of FSH / hMG / Menopur per fill but limited to 4 lifetime fills). Also look at Age Limits (e.g. 44 or under for hCG), which might be waived with a Prior Authorization. Sometimes, “Step Therapy” is required where you have to trial a cheaper type/brand first (e.g., allergy, ineffectiveness or sensitivity to generic Testosterone Cypionate before getting approved for Androgel, Testopel, Natesto, Xyosted, etc.; or trial of Ovidrel or generic hCG prior to approval for Pregnyl). Sometimes there are Gender Exclusions (e.g. hCG / hMG only allowed for women) but those can often be overridden by a Prior Authorization from your physician.

2) Medical vs. Drug Coverage. Some people have separate drug and medical coverage. In this case, sometimes the fertility medications (hcg, hmg) and in-office TRT (Testopel pellets, Aveed injections) are covered by the medical plan instead of the drug plan. So, it is important to contact both plans to ask what your coverage is, making sure to provide the correct ICD-10 diagnosis code and CPT / HCPS procedure codes (ask your doctor if unsure).

3) Fertility Coverage. In some plans, coverage for hCG, hMG, r-FSH or Clomiphene falls under the category of fertility treatments. That actually makes it easier to get approval via prior authorization, especially if you already had semen analysis. There can be age limits, often 39 or 44 years old or younger, when billing under a fertility diagnosis code.

4) Compounded Drug Coverage. Some plans flat out refuse to pay for compounded medications, but others have certain policies that may make it possible to receive at least partial reimbursement. For example, some plans will cover any FDA-approved ingredients (such as testosterone itself, alprostadil in Trimix, tamoxifen in a cream, etc.) so long as the compounding pharmacy specifies all ingredients and their percentages (side note - Empower refuses to do this). You would also need a justification from your physician as to why the compounded product is needed versus a commercially available drug. The insurance company will need to provide you the policy and procedures. (Another side note, it is far more difficult to get reimbursed when the medication is purchased from a TRT clinic instead of directly from the compounding pharmacy. This is due to the additional information required that would not be included in your medical bill, such as NDC codes (ID of the drug), NPI (ID of the pharmacy and prescribing physician), and other details that you usually get from a pharmacy).

5) FDA Labels. It pays to look closely at the prescription label for your medication to find FDA-approved uses that the insurance company has not considered. A great example is my recent experience with Pregnyl. It appears in the formulary as being allowed only for women and only 5 lifetime fills, up to age 44. However, the FDA label specifically states that Pregnyl is approved for “select cases of secondary hypogonadism” such as that caused by pituitary issues, low LH, low FSH, or hypothalamus issues. I happen to be on TRT for hypogonadotropic hypogonadism (small testicles and low testosterone production due to low LH and low FSH), so when the doctor included this diagnosis code and the FDA verbiage in the prior authorization, it was approved. Now I just have to pay a small copay for Pregnyl instead of hundreds thru Defy/Empower or uncertain doses from Indian pharmacies.

6) Prior Authorizations (PA). This is key. In most cases, your physician will need to submit a prior authorization for TRT and fertility drugs. Thus, it pays to do your research in the previous steps so you can provide the needed information to your doctor. Another important aspect is ensuring you are discussing “signs and symptoms” at every appointment so they get documented, such as hot flashes, decreased muscle mass, decreased body and facial hair, fatigue, low libido, ED, etc.

7) Excluded Drugs. If the formulary says a drug is excluded, you might have a couple of options. It might get approved with a good justification from your doctor as to why that specific product/brand is needed in YOUR case, with relevant medical history to prove it. You can also request that a drug be added to the formulary, which is no guarantee and is often an obscure process that no one wants to tell you about, but it might be worth it if it will help you decrease out of pocket costs long term.

So why go through all this trouble? Well, if you are paying for insurance, you might as well get a return on your investment. Also, even modest monthly out-of-pocket costs at TRT clinics will add up over time. Think about it - $200 per month sounds affordable until you realize it means $2,400 per year or $24,000 after 10 years. TRT is usually for life. So, wouldn’t it be better to pay a $10-$75 copay instead?

I hope you guys find these tips useful. Please feel free to comment below if you have additional tips, corrections or to share your story dealing with insurance.

---------------------------
Other Tips Compiled From Conversations Below

* Consider Prescription Savings Cards.
Companies like GoodRx can sometimes give you a cheaper price at the pharmacy counter compared to insurance (or no insurance). For example, a 90-day supply of Cialis 5mg daily can cost $15-$25, compared to $30-$75 with insurance (and mine will only pay for 6 tablets per month anyway, not 30). Testosterone Cypionate can cost $10-$70 depending on the pharmacy. Note that some pharmacies do not take savings cards for controlled substances like testosterone.

* Look for Manufacturer Savings Programs. Many pharmaceutical companies have "co-pay assistance" or "prescription savings" programs, especially for the super expensive or specialty meds that do not have generics (think Natesto, Xyosted). Co-pay assistance cards can often bring down your co-pay to $0 (Natesto, Edex) - you just ask the pharmacy to run it as secondary insurance. Such programs are limited to those with commercial insurance either through work or the Marketplace (so that excludes Medicaid, Medicare, Tricare). Prescription savings programs usually require an application and proof of low income, but they can get you brand-name medications for $0 in some cases (Cialis, Pregnyl) or around $100 in others (Natesto, Xyosted).
 
Last edited:
Defy Medical TRT clinic doctor
I see a lot of posts here from U.S. users stating that “insurance does not pay” for hCG, FSH, Trimix, and even some testosterone products. Although that may be true of some health plans, I have found that coverage is often permitted via prior authorizations and paying close attention to formularies. I compiled a few tips for getting insurance coverage that I’ve learned over the years. I hope this helps.

1) Peruse the Formulary. Each drug plan has a list of covered drugs and specifically excluded drugs called a formulary. Request it from your insurance company or HR department, and find the coverage limitations for your prescription. Look at Quantity Limit (e.g. only 6 vials or autoinjectors of alpostradil (Caverject/Edex) for ED per month, or 15 vials of FSH / hMG / Menopur per fill but limited to 4 lifetime fills). Also look at Age Limits (e.g. 44 or under for hCG), which might be waived with a Prior Authorization. Sometimes, “Step Therapy” is required where you have to trial a cheaper type/brand first (e.g., allergy, ineffectiveness or sensitivity to generic Testosterone Cypionate before getting approved for Androgel, Testopel, Natesto, Xyosted, etc.; or trial of Ovidrel or generic hCG prior to approval for Pregnyl). Sometimes there are Gender Exclusions (e.g. hCG / hMG only allowed for women) but those can often be overridden by a Prior Authorization from your physician.

2) Medical vs. Drug Coverage. Some people have separate drug and medical coverage, even through different companies. In this case, sometimes the fertility medications (hcg, hmg) and in-office TRT (Testopel pellets, Aveed injections) are covered by the medical plan instead of the drug plan. So, it is important to contact both plans to ask what your coverage is, making sure to provide the correct ICD-10 diagnosis code and CPT / HCPS procedure codes (ask your doctor if unsure).

3) Fertility Coverage. In some plans, coverage for hCG, hMG, r-FSH or Clomiphene falls under the category of fertility treatments. That actually makes it easier to get approval via prior authorization, especially if you already had semen analysis, but the downside is there will be age limits, often 39 or 44 years old or younger.

4) Compounded Drug coverage. Some plans flat out do not pay for compounded medications, but others have certain policies that may make it possible to receive at least partial reimbursement. For example, some plans will cover any FDA-approved ingredients (such as testosterone itself, alprostadil in Trimix, tamoxifen in a cream, etc.) so long as the compounding pharmacy specifies all ingredients and their percentages (side note - Empower refuses to do this). You would also need a justification from your physician as to why the compounded product is needed versus a commercially available drug. The insurance company will need to provide you the policy and procedures. (Another side note, it is far more difficult to get reimbursed when the medication is purchased from a TRT clinic such as Defy instead of directly from the compounding pharmacy).

5) FDA Labels. It pays to look closely at the prescription label for your medication to find FDA-approved uses that the insurance company has not considered. A great example is my recent experience with Pregnyl. It appears in the formulary as being allowed only for women and only 5 lifetime fills, up to age 44. However, the FDA label specifically states that Pregnyl is approved for “select cases of secondary hypogonadism” such as that caused by pituitary issues, low LH, low FSH, or hypothalamus issues. I happen to be on TRT for hypogonadotropic hypogonadism (small testicles and low testosterone production due to low LH and low FSH), so when the doctor included this diagnosis code and the FDA verbiage in the prior authorization, it was approved. Now I just have to pay a small copay for Pregnyl instead of hundreds thru Defy/Empower or uncertain doses from Indian pharmacies.

6) Prior Authorizations (PA). This is key. In most cases, your physician will need to submit a prior authorization for TRT and fertility drugs. Thus, it pays to do your research in the previous steps so you can provide the needed information to your doctor. Another important aspect is ensuring you are discussing “signs and symptoms” at every appointment so they get documented, such as hot flashes, decreased muscle mass, decreased body and facial hair, fatigue, low libido, ED, etc.

7) Excluded Drugs. If the formulary says a drug is excluded, you might have a couple of options. It might get approved with a good justification from your doctor as to why that specific product/brand is needed in YOUR case, with relevant medical history to prove it. You can also request that a drug be added to the formulary, which is no guarantee and is often an obscure process that no one wants to tell you about, but it might be worth it if it will help you decrease out of pocket costs long term.

So why go through all this trouble? Well, if you are paying for insurance, you might as well get a return on your investment. Also, even modest monthly out-of-pocket costs at TRT clinics will add up over time. Think about it - $200 per month sounds affordable until you realize it means $2,400 per year or $24,000 after 10 years. TRT is usually for life. So, wouldn’t it be better to pay a $20-$75 copay instead?

I hope you guys find these tips useful. Please feel free to comment below if you have additional tips, corrections or to share your story dealing with insurance.
Devil always in the details. Nice work
Testosterone is cheap. TRT (legit with Doc, etc) should not cost you more than $1000 (USD) per year if you do your homework. UGL cheaper if you have that risk profile.
 
Wait, the link is for 1 10ml vial. Now, this is interesting. The price for a 10ml vial and the price for 1ml used to be the same per ml.

Sometimes I’d get 10ml from CVS even when my doctor wrote up 10 1ml’s. But then CVS stopped dispensing them even when my doctor did write up one 10ml. They said they no longer dispense 10ml.

But anyway, that’s neither here nor there. I did get a 10ml once from Walgreens but usually got 12 1ml’s. If I go back on, I’ll definitely ask my doctor to write up one 10ml.
IMG_3040.png
 
Wait, the link is for 1 10ml vial. Now, this is interesting. The price for a 10ml vial and the price for 1ml used to be the same per ml.

Sometimes I’d get 10ml from CVS even when my doctor wrote up 10 1ml’s. But then CVS stopped dispensing them even when my doctor did write up one 10ml. They said they no longer dispense 10ml.

But anyway, that’s neither here nor there. I did get a 10ml once from Walgreens but usually got 12 1ml’s. If I go back on, I’ll definitely ask my doctor to write up one 10ml.View attachment 47162
Yeah CVS is a pain in the ass. They won't dispense 10 ml vial I've heard. Walgreens, I've had no problem. But if on a 100 mg per week test cyp Rx they want to give me 1 ml (200 mg/ml) vial per week, I ain't going to argue. Inventory.

Kinda moot now as I have upped my Rx to 200 mg/week. But on the lower TRT Rx, a guy can clean up with these silly SDV vs MDV rules at CVS. They seem to think it is perfectly reasonably for the patient to throw away 50% of their Rx med.
 
In my area area (Northern Ohio) I was getting a 10ml/200mg/ml vial at Rite Aid for $28.00 with a GoodRx coupon. Now most of the RiteAid's in Ohio has closed. Walgreens in my area would not accept GoodRx because Testosterone is a controlled drug. Now I have to look for a pharmacy that will accept GoodRx. One of my local grocery stores will accept it, but will cost me $62. Another Pharmacy who has it for $35 will not accept it because of the schedule of testosterone.
I am on Medicare, and have a supplemental prescription plan through Wellcare and they do not not cover Testosterone. My Dr writes my script for 10ml/200mg/ml.
 
I don’t use insurance for my TRT and ED medications because GoodRx has a lower price than my insurance. I can get a three month supply of 5mg cialis daily (generic) for $18.61 and a 10ml vial of testosterone cypionate 200mg/ml for $40.47. With GoodRx you can get 90 generic viagra 100mg pills for $15.90. If you cut them in half that is under 10 cents for a 50mg dose which is practically free. Cialis daily is about 20 cents a day.
 
Yes, depending on your copays, GoodRx can be a better value especially for popular generics like test cyp, tadalafil (cialis) and sildenafil (viagra). In my case, I use GoodRx Gold for daily cialis but everything else has a copay of only $10 so it is cheaper with insurance. There are some exception, with the "tier 3" or super expensive meds with no generics, like Cavarject, Pregnyl and Natesto, which have a $75 copay... but even that is way cheaper than buying through Empower or a retail pharmacy with GoodRx. However I found manufacturer copay cards that brought my copay down to $0. I am thinking of trying pellets next, and those would be covered 100% in full including the insertion procedure.

For more specialty meds, always look for manufacturer "co-pay assistance" programs. Sometimes they will bring your copay down to $0. And if you don't have insurance, look for manufacturer "prescription savings" programs which will get you the super expensive meds for free or less than $100/mo.
 
Beyond Testosterone Book by Nelson Vergel
I see a lot of posts here from U.S. users stating that “insurance does not pay” for hCG, FSH, Trimix, and even some testosterone products. Although that may be true of some health plans, I have found that coverage is often permitted via prior authorizations and paying close attention to formularies. I compiled a few tips for getting insurance coverage that I’ve learned over the years. I hope this helps.

1) Peruse the Formulary. Each drug plan has a list of covered drugs and specifically excluded drugs called a formulary. Request it from your insurance company or HR department, and find the coverage limitations for your prescription. Look at Quantity Limit (e.g. only 6 vials or autoinjectors of alpostradil (Caverject/Edex) for ED per month, or 15 vials of FSH / hMG / Menopur per fill but limited to 4 lifetime fills). Also look at Age Limits (e.g. 44 or under for hCG), which might be waived with a Prior Authorization. Sometimes, “Step Therapy” is required where you have to trial a cheaper type/brand first (e.g., allergy, ineffectiveness or sensitivity to generic Testosterone Cypionate before getting approved for Androgel, Testopel, Natesto, Xyosted, etc.; or trial of Ovidrel or generic hCG prior to approval for Pregnyl). Sometimes there are Gender Exclusions (e.g. hCG / hMG only allowed for women) but those can often be overridden by a Prior Authorization from your physician.

2) Medical vs. Drug Coverage. Some people have separate drug and medical coverage. In this case, sometimes the fertility medications (hcg, hmg) and in-office TRT (Testopel pellets, Aveed injections) are covered by the medical plan instead of the drug plan. So, it is important to contact both plans to ask what your coverage is, making sure to provide the correct ICD-10 diagnosis code and CPT / HCPS procedure codes (ask your doctor if unsure).

3) Fertility Coverage. In some plans, coverage for hCG, hMG, r-FSH or Clomiphene falls under the category of fertility treatments. That actually makes it easier to get approval via prior authorization, especially if you already had semen analysis. There can be age limits, often 39 or 44 years old or younger, when billing under a fertility diagnosis code.

4) Compounded Drug Coverage. Some plans flat out refuse to pay for compounded medications, but others have certain policies that may make it possible to receive at least partial reimbursement. For example, some plans will cover any FDA-approved ingredients (such as testosterone itself, alprostadil in Trimix, tamoxifen in a cream, etc.) so long as the compounding pharmacy specifies all ingredients and their percentages (side note - Empower refuses to do this). You would also need a justification from your physician as to why the compounded product is needed versus a commercially available drug. The insurance company will need to provide you the policy and procedures. (Another side note, it is far more difficult to get reimbursed when the medication is purchased from a TRT clinic instead of directly from the compounding pharmacy. This is due to the additional information required that would not be included in your medical bill, such as NDC codes (ID of the drug), NPI (ID of the pharmacy and prescribing physician), and other details that you usually get from a pharmacy).

5) FDA Labels. It pays to look closely at the prescription label for your medication to find FDA-approved uses that the insurance company has not considered. A great example is my recent experience with Pregnyl. It appears in the formulary as being allowed only for women and only 5 lifetime fills, up to age 44. However, the FDA label specifically states that Pregnyl is approved for “select cases of secondary hypogonadism” such as that caused by pituitary issues, low LH, low FSH, or hypothalamus issues. I happen to be on TRT for hypogonadotropic hypogonadism (small testicles and low testosterone production due to low LH and low FSH), so when the doctor included this diagnosis code and the FDA verbiage in the prior authorization, it was approved. Now I just have to pay a small copay for Pregnyl instead of hundreds thru Defy/Empower or uncertain doses from Indian pharmacies.

6) Prior Authorizations (PA). This is key. In most cases, your physician will need to submit a prior authorization for TRT and fertility drugs. Thus, it pays to do your research in the previous steps so you can provide the needed information to your doctor. Another important aspect is ensuring you are discussing “signs and symptoms” at every appointment so they get documented, such as hot flashes, decreased muscle mass, decreased body and facial hair, fatigue, low libido, ED, etc.

7) Excluded Drugs. If the formulary says a drug is excluded, you might have a couple of options. It might get approved with a good justification from your doctor as to why that specific product/brand is needed in YOUR case, with relevant medical history to prove it. You can also request that a drug be added to the formulary, which is no guarantee and is often an obscure process that no one wants to tell you about, but it might be worth it if it will help you decrease out of pocket costs long term.

So why go through all this trouble? Well, if you are paying for insurance, you might as well get a return on your investment. Also, even modest monthly out-of-pocket costs at TRT clinics will add up over time. Think about it - $200 per month sounds affordable until you realize it means $2,400 per year or $24,000 after 10 years. TRT is usually for life. So, wouldn’t it be better to pay a $10-$75 copay instead?

I hope you guys find these tips useful. Please feel free to comment below if you have additional tips, corrections or to share your story dealing with insurance.

---------------------------
Other Tips Compiled From Conversations Below

* Consider Prescription Savings Cards.
Companies like GoodRx can sometimes give you a cheaper price at the pharmacy counter compared to insurance (or no insurance). For example, a 90-day supply of Cialis 5mg daily can cost $15-$25, compared to $30-$75 with insurance (and mine will only pay for 6 tablets per month anyway, not 30). Testosterone Cypionate can cost $10-$70 depending on the pharmacy. Note that some pharmacies do not take savings cards for controlled substances like testosterone.

* Look for Manufacturer Savings Programs. Many pharmaceutical companies have "co-pay assistance" or "prescription savings" programs, especially for the super expensive or specialty meds that do not have generics (think Natesto, Xyosted). Co-pay assistance cards can often bring down your co-pay to $0 (Natesto, Edex) - you just ask the pharmacy to run it as secondary insurance. Such programs are limited to those with commercial insurance either through work or the Marketplace (so that excludes Medicaid, Medicare, Tricare). Prescription savings programs usually require an application and proof of low income, but they can get you brand-name medications for $0 in some cases (Cialis, Pregnyl) or around $100 in others (Natesto, Xyosted).

Lots of great info here and some that I've accidently stumbled upon myself. Searching for this solution and found this thread, close but need a little help.

Situation: Been injecting Enanthate for almost 3 years, results have been life changing for me. Quality of life has tripled. Zero side effects, other than estrogen running high after the first two years so take a 1mg arimidex every 10 days or so to keep the E down. Don't like it but don't want to risk side effects.

I use GoodRX at CVS to get 3 vials of Enanthate for about 75 bucks for 3 months.

PCP retired, new PCP reads the blood work, T is running 950 and according to his teachings above 700 is bad for you and will cause serious problems, he's telling me that he'll dial down the prescription to bring it under 700 or I need to go somewhere else.

I'm scheduling an appt with Urologist, but need a simpler solution I think.

Question: These Men's Health or Executive Clinics seem to charge several hundred a month to get T from them (sounds like a drug dealer). I just need a legal place for a prescription so I can take it to CVS. I can go to my PCP to run the bloodwork.

Need to figure out how to keep my T right around 900 to 1000. Options? Point me to a thread?
 
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