Does Medicare Cover Testosterone Therapy?

Medicare, the federal health insurance program for individuals aged 65 or older and certain younger people with disabilities, covers a wide range of medical services. Understanding Medicare coverage for specific needs like testosterone therapy involves navigating different program parts and their rules, considering how and where treatment is administered, and its medical necessity.

Medicare Parts and Testosterone Therapy Coverage

Medicare’s structure dictates how testosterone therapy might be covered, primarily through Part B and Part D. Medicare Part B generally covers services administered by a healthcare professional in an outpatient setting. This includes doctor visits, diagnostic laboratory tests for testosterone levels, and testosterone injections or pellet implants provided in a physician’s office or clinic. For Part B to cover these services, they must be medically necessary.

Testosterone supplements or other hormone replacement therapies self-administered at home, such as gels, patches, or self-injected medications, are covered under Medicare Part D. Part D plans are prescription drug plans offered by private companies approved by Medicare. Coverage for these medications depends on the specific formulary, or list of covered drugs, of an individual’s chosen Part D plan.

Medicare Advantage Plans (Part C) are offered by private companies approved by Medicare and include all Part A and Part B benefits. Many Medicare Advantage plans also incorporate prescription drug coverage, similar to Part D. These plans may cover both in-office and self-administered testosterone therapy, depending on the specific plan’s details and formulary. Reviewing the plan’s terms is important, as coverage for certain brand-name drugs may vary.

Conditions for Coverage

Medicare’s coverage for testosterone therapy requires medical necessity, meaning the treatment must diagnose or treat a specific medical condition. For testosterone therapy, this typically means a diagnosis of hypogonadism, a condition where the body does not produce enough testosterone due to a disorder of the testicles, pituitary gland, or brain. The therapy is not covered if low testosterone levels are simply due to aging, often referred to as late-onset hypogonadism, as this is not considered medically necessary.

To establish medical necessity, a physician must provide a confirmed diagnosis supported by documented medical history and laboratory tests. This often involves at least two morning blood tests showing consistently low testosterone levels. The prescribed testosterone product must be approved by the U.S. Food and Drug Administration (FDA) for the specific indication of hypogonadism. Ongoing physician monitoring, including regular blood tests and prostate evaluations, is required to ensure the therapy remains appropriate and safe.

Medicare may not cover testosterone therapy for conditions like idiopathic hypogonadism, where there is no clear cause, or for individuals with certain health risks. For example, those with a history of prostate or breast cancer, or who have experienced a heart attack, stroke, or specific blood clot issues within the past six months, may not qualify for coverage. The therapy is intended for replacement in cases of confirmed deficiency due to specific medical disorders, not for general enhancement or age-related decline.

Understanding Your Costs

Even when Medicare covers testosterone therapy, beneficiaries are responsible for out-of-pocket costs. For services covered under Medicare Part B, such as in-office injections, individuals must first satisfy an annual deductible, which is $257 in 2025. After meeting this deductible, Medicare typically pays 80% of the approved amount, with the beneficiary responsible for the remaining 20% coinsurance.

For prescription medications covered under Medicare Part D, costs include a monthly premium, an annual deductible, and copayments or coinsurance. The standard Part D deductible for 2025 can be up to $590, though some plans may offer a lower or zero deductible. Once met, beneficiaries typically pay a percentage, often 25%, of drug costs during the initial coverage period.

A significant change for 2025 is the elimination of the “donut hole,” or coverage gap, in Part D. Once a beneficiary’s out-of-pocket costs for covered drugs reach $2,000 in 2025, they enter the catastrophic coverage phase, paying nothing for covered drugs for the remainder of the calendar year. These costs vary significantly based on the specific Medicare Advantage or Part D plan chosen, as each plan has its own formulary and cost-sharing structure.

Steps to Confirm Coverage

Confirming Medicare coverage for testosterone therapy involves understanding your individual plan’s benefits. Begin by discussing your medical necessity and treatment plans with your doctor. Your physician can provide the diagnosis and documentation required for Medicare coverage.

Next, contact your specific Medicare Part D or Medicare Advantage plan directly. Inquire about their formulary to determine if the prescribed testosterone medication is covered and its cost-sharing tier. Formularies can be found on your plan’s website or by calling their member services number. Understanding the drug’s tier helps estimate out-of-pocket expenses, as lower tiers typically have lower costs.

Many plans require prior authorization for testosterone therapy, especially for certain formulations or brand-name drugs. This process involves your doctor submitting documentation to your plan to demonstrate medical necessity before coverage is approved. Address prior authorization requirements early to avoid unexpected costs or delays in receiving medication.