Does Medicare Cover Hormone Therapy?
Explore Medicare's coverage of hormone therapy. Get clear insights into what's covered, for whom, and how to manage potential costs and access care.
Hormone therapy involves administering hormones to address various health conditions, from managing menopause symptoms to treating disorders and supporting gender-affirming care. Many individuals rely on these therapies to improve their quality of life. Medicare coverage for hormone therapy depends on several factors, including the specific plan, medical necessity, and administration method. This article aims to clarify how Medicare generally covers hormone therapy, providing a foundational understanding for beneficiaries.
Understanding Medicare Coverage Basics for Hormone Therapy
Medicare has different parts covering specific medical services and prescription drugs. Original Medicare, comprising Part A and Part B, forms the program’s foundation. Medicare Part A, or Hospital Insurance, primarily covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health services. Part A covers hormone therapy only if administered during an inpatient hospital stay for a related medical condition.
Medicare Part B, or Medical Insurance, covers medically necessary doctor visits, outpatient services, medical supplies, and certain preventive services. Part B may cover the administration of hormone therapy, such as clinic injections, and associated doctor visits and diagnostic tests. However, it does not cover self-administered hormone medications. For these, beneficiaries typically use Medicare Part D, which provides prescription drug coverage through private Medicare-approved insurance companies.
Medicare Advantage Plans (Part C) offer an alternative to Original Medicare. These private plans, approved by Medicare, must cover all Original Medicare Part A and B benefits. Many also include Part D prescription drug coverage, often with different rules, costs, and additional benefits.
Specific Coverage Scenarios for Hormone Therapy
Medicare’s coverage of hormone therapy depends on medical necessity. A healthcare provider must determine the treatment is required to diagnose or treat a specific medical condition, ensuring it serves health purposes rather than cosmetic or non-medical reasons.
For individuals undergoing gender-affirming care, Medicare covers medically necessary hormone therapy for gender dysphoria. This coverage is treated similarly to other medical conditions, and the medications are typically covered under Medicare Part D. While coverage decisions are made on a case-by-case basis, Medicare includes related services like counseling.
Hormone therapy for certain cancers, such as breast or prostate cancer, is covered when medically necessary. Similarly, hormone therapy for endocrine disorders like hypothyroidism, growth hormone deficiency, adrenal insufficiency, or low testosterone in men is also covered. Coverage depends on whether hormones are administered in an outpatient setting (Part B) or self-administered as a prescription (Part D).
Hormone therapy for managing menopausal symptoms is covered if medically necessary and not for “anti-aging” purposes. Coverage varies based on the hormone formulation (pills, patches, gels, injections) and whether the drug is on a Part D plan’s formulary. Beneficiaries should check their Part D plan’s formulary for specific medication coverage and cost-sharing.
Navigating Costs and Accessing Coverage
Beneficiaries often incur out-of-pocket costs even when Medicare covers hormone therapy. Under Original Medicare Part B, after meeting the annual deductible ($257 in 2025), beneficiaries typically pay 20% coinsurance of the Medicare-approved amount for most covered services, including doctor visits and hormone therapy administration. Medicare Part D plans, covering prescription drugs, also have their own cost-sharing structures. These typically include an annual deductible (up to $590 in 2025) and then co-payments or co-insurance for medications.
Medicare Part D plans organize covered drugs into different tiers on their formularies. Lower-tier drugs, often generics, usually have lower co-payments. Higher-tier drugs, such as brand-name or specialty drugs, typically incur higher costs. Starting in 2025, an annual cap of $2,000 applies to out-of-pocket prescription drug costs for Part D covered drugs. After reaching this cap, beneficiaries pay nothing for covered prescriptions for the rest of the year.
Medicare Advantage plans (Part C) have their own cost-sharing rules. These plans have an out-of-pocket maximum for Part A and Part B services, which is $9,350 for in-network services in 2025, protecting beneficiaries from excessive costs. Part D spending typically does not count towards this Part A/B maximum.
Prior authorization is often required for hormone therapy, meaning Medicare or the specific plan must approve the treatment before it is administered or covered. Healthcare providers play a crucial role in submitting thorough medical documentation to support the medical necessity of the prescribed hormone therapy. If coverage is denied, beneficiaries have the right to appeal the decision through a multi-level appeals process. This process allows individuals to formally challenge a denial and provide additional information to support their claim.