Does Medicare Cover Testosterone Gel?

Medicare provides health insurance to millions of Americans, but understanding its various parts and how they cover specific medications like testosterone gel can be challenging. This article aims to clarify Medicare’s role in covering testosterone gel, detailing the relevant parts of Medicare, coverage specifics, financial responsibilities, and steps for navigating requirements and addressing denials.

Medicare Parts and Prescription Drug Coverage

Medicare generally covers prescription drugs through Part D, which is prescription drug insurance offered by private companies approved by Medicare. Most outpatient prescription drugs, including self-administered medications like testosterone gel, are covered by Part D. You can obtain Part D through a stand-alone plan if you have Original Medicare (Parts A and B), or it may be included as part of a Medicare Advantage Plan (Part C).

Medicare Part B (Medical Insurance) covers a limited set of drugs, primarily those administered by a healthcare provider in a clinical setting. While some testosterone treatments might be given as injections in a doctor’s office and thus covered by Part B, testosterone gel, being self-administered, is typically not covered under Part B. Medicare Part A (Hospital Insurance) covers drugs administered during a Medicare-covered inpatient hospital or skilled nursing facility stay.

Medicare Advantage Plans (Part C) are an alternative way to receive Medicare benefits, bundling Part A, Part B, and often Part D coverage. Offered by private companies, these plans must provide at least the same benefits as Original Medicare, and often include additional benefits like prescription drug coverage. If a Medicare Advantage Plan includes prescription drug coverage, it functions similarly to a Part D plan for outpatient medications.

Coverage Specifics for Testosterone Gel

Testosterone gel is typically covered under Medicare Part D plans, provided it is deemed medically necessary and prescribed by a physician. A significant majority of Medicare prescription drug plans cover testosterone. However, coverage is not universal, and the specific brand or generic version of testosterone gel may vary in coverage across different plans.

Each Part D plan maintains a “formulary,” a list of covered prescription drugs. Testosterone gel’s inclusion on a plan’s formulary, and its placement on a specific cost-sharing tier, can differ greatly among plans. Drugs on lower tiers generally have lower out-of-pocket costs than those on higher tiers. Some plans may also require “prior authorization,” meaning the plan must approve the medication before coverage, or “step therapy,” which requires trying a less expensive alternative drug first.

Navigating Coverage Requirements

To determine if your specific testosterone gel is covered, you should check your Medicare Part D plan’s formulary. This list is available on the plan’s website or by contacting the plan directly. The formulary will indicate if the medication is covered and its assigned cost-sharing tier.

If your plan requires prior authorization for testosterone gel, your doctor will need to submit documentation to the plan. This documentation includes your diagnosis, medical history, past treatments, and relevant lab results that justify the medical necessity of the testosterone gel.

For step therapy requirements, you may need to demonstrate that less costly alternatives were tried and were ineffective or caused adverse side effects before the plan will cover testosterone gel.

Understanding Your Financial Responsibility

Even when testosterone gel is covered by a Medicare Part D plan, you will have financial responsibilities that contribute to your overall costs. Most Part D plans have an annual deductible, an amount you must pay out-of-pocket before your plan begins to cover costs. In 2025, the maximum deductible for prescription drug plans is $590.

After meeting the deductible, you will pay a copayment, which is a fixed dollar amount, or coinsurance, a percentage of the drug’s cost, for each prescription. These amounts vary based on the drug’s tier on the formulary, with higher-tier drugs generally having greater out-of-pocket costs.

You continue to pay these copayments or coinsurance amounts until your total out-of-pocket spending reaches a certain threshold, which for 2025 is $2,000 in the initial coverage stage.

Once your out-of-pocket spending reaches this threshold, you enter the “coverage gap,” also known as the “donut hole,” where you pay a higher percentage of the drug’s cost. After spending a certain amount in the coverage gap, you enter “catastrophic coverage,” where your out-of-pocket costs for covered drugs significantly decrease. All these costs contribute to your overall annual out-of-pocket maximum, providing a limit to your financial exposure.

Obtaining Prescriptions and Addressing Denials

Obtaining your testosterone gel prescription begins with your doctor writing the prescription, ensuring it specifies the correct dosage and form. You can then fill this prescription at a pharmacy that is part of your Medicare Part D plan’s network. It is advisable to confirm with the pharmacy that they accept your plan before filling the prescription.

If coverage for your testosterone gel is denied at the pharmacy, due to a missing prior authorization or formulary exclusion, you should immediately contact your Medicare Part D plan or your prescribing doctor’s office. The denial notice from the pharmacy or plan will provide a reason for the denial, which is helpful in addressing the issue.

You have the right to appeal a coverage denial. The first step involves initiating an appeal directly with your Part D plan, by submitting a written request with supporting medical documentation from your doctor.

There are different levels of appeal, including standard and expedited processes depending on the urgency of your medical need. If the internal appeals with your plan are unsuccessful, you can pursue an external review by an independent organization, ensuring an impartial assessment of your case.