How to Get Testosterone Covered by Medicare

Medicare, a federal health insurance program, helps millions manage healthcare expenses. Understanding its components and coverage pathways is important for beneficiaries to make informed decisions about medical and prescription drug costs.

Medicare Prescription Drug Coverage Basics

Medicare Part A provides coverage for inpatient hospital stays, skilled nursing facility care, hospice care, and some home health services. Medicare Part B covers outpatient medical services, including doctor visits, medical supplies, and preventive services. Original Medicare consists of Part A and Part B, allowing beneficiaries to choose their healthcare providers who accept Medicare.

Prescription drug coverage is primarily offered through Medicare Part D. This optional coverage is provided by private insurance companies approved by Medicare. Individuals with Original Medicare can enroll in a standalone Prescription Drug Plan (PDP) to add drug coverage. Alternatively, many Medicare Advantage (Part C) plans, which combine Part A and Part B benefits, also include Part D prescription drug coverage.

Each Part D plan maintains a list of covered medications known as a formulary. This formulary outlines the generic and brand-name drugs the plan covers, typically organizing them into different tiers. Drugs in lower tiers generally have lower out-of-pocket costs, while those in higher tiers, such as specialty drugs, may incur greater expenses. Plans are required to cover at least two drugs in most therapeutic categories, ensuring a range of options for beneficiaries.

Criteria for Testosterone Therapy Coverage

Medicare may cover testosterone replacement therapy (TRT) when it is medically necessary for specific conditions. This typically includes symptomatic hypogonadism resulting from a disorder of the testicles, pituitary gland, or brain. Coverage may also extend to delayed male puberty and gender dysphoria, provided the individual can make an informed decision regarding hormone therapy.

Medicare generally does not cover TRT for late-onset hypogonadism due to aging. Similarly, idiopathic hypogonadism, which lacks a clear cause or is not linked to disorders of the testicles, pituitary gland, or brain, is usually not covered. Individuals diagnosed with prostate cancer or breast cancer, or those who have experienced certain cardiovascular events like a heart attack or stroke within the past six months, may also be excluded from coverage.

To establish medical necessity, comprehensive documentation is required. This includes physician notes detailing symptoms consistent with low testosterone, such as decreased energy or sleep disturbances. Laboratory results from at least two separate serum testosterone levels, taken on different mornings, must consistently show low testosterone levels. For men with levels between 200-300 ng/dL and conditions affecting sex hormone binding globulin, such as obesity or type 2 diabetes, a free testosterone level should be obtained.

Further supporting documentation might involve lab results indicating elevated luteinizing hormone (LH) or follicle-stimulating hormone (FSH) for primary hypogonadism. If LH or FSH levels are low, an assessment for pituitary disease and other chronic conditions must be documented to rule out alternative causes.

Navigating the Approval Process

Once medical necessity for testosterone therapy has been established by a healthcare provider, Medicare Part D plans often require a process called “Prior Authorization” (PA).

Prior Authorization means the insurance plan needs to approve the medication before it will be covered. This step helps ensure the drug is medically appropriate and necessary for the patient’s condition. The doctor’s office typically handles submitting the required documentation, including lab results and clinical notes, to the Part D plan for review.

Another common coverage management tool is “Step Therapy.” Under step therapy, a plan may require a patient to try a less expensive, yet effective, alternative medication first. Only if the initial medication proves ineffective or causes adverse reactions will the plan then consider covering the more expensive, originally prescribed drug. If a coverage decision is unfavorable, beneficiaries have the right to appeal.

The appeals process typically involves several levels.
Level 1: A request for redetermination with the Part D plan, filed within 60 days of the denial notice.
Level 2: If the plan upholds its denial, a reconsideration can be filed with an Independent Review Entity (IRE).
Level 3: Appeals can proceed to an Administrative Law Judge.
Level 4: Appeals can proceed to the Medicare Appeals Council.
Level 5: Appeals can proceed to a federal district court if the dispute meets certain monetary thresholds.

Understanding Your Share of Costs

Beneficiaries incur various out-of-pocket costs when testosterone therapy is covered by a Medicare Part D plan. The annual deductible is the initial amount a person must pay for covered prescription drugs before their plan begins to contribute. For 2025, the maximum deductible a Part D plan can charge is $590, though some plans may have a lower or no deductible.

After the deductible is met, beneficiaries enter the initial coverage phase. During this phase, the plan pays a portion of the drug cost, and the enrollee pays a copayment or coinsurance. A copayment is a fixed dollar amount for a prescription, while coinsurance is a percentage of the drug’s cost. The specific amount depends on the drug’s tier on the plan’s formulary, with higher tiers generally having greater cost-sharing.

Historically, a coverage gap, often called the “donut hole,” existed where beneficiaries paid a higher percentage of drug costs after reaching a certain spending limit. However, as of 2025, the coverage gap has been eliminated. Once total out-of-pocket spending on covered drugs reaches $2,000 in 2025, beneficiaries enter the catastrophic coverage phase.

In the catastrophic coverage phase, beneficiaries pay nothing for covered Part D drugs for the remainder of the calendar year. Individuals with limited income and resources may also qualify for the Low-Income Subsidy (LIS), also known as “Extra Help,” which assists with Part D premiums, deductibles, and copayments, further reducing out-of-pocket costs.