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).
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).
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