Does Medicare Cover Hormone Therapy for Menopause?
This article was updated on: 09/10/2018
Menopause (also called “change of life”) is when a woman has her last menstrual period. According to the U.S. National Library of Medicine (NLM), the average age of menopause is 51. Menopause changes the balance of hormones in a woman’s body, which can sometimes lead to menopause symptoms such as hot flashes, thinning and drying of the vagina, trouble falling asleep, and mood swings. A doctor may recommend hormone therapy to relieve the symptoms of menopause.
What is hormone therapy for menopause?
Hormone therapy may also treat long-term changes such as bone loss that result from declining levels of estrogen and progesterone, according to the National Cancer Institute. According to the Food and Drug Administration (FDA), hormone therapy could come as a pill, patch, gel, vaginal cream, vaginal insert, skin spray, skin cream, or injection.
Hormone therapy drugs include:
- Estrogen alone (brand name drugs include: Premarin, Estraderm, Divigel, Cenestin, Climara among many others)
- Progestin alone (brand name drugs include Prometrium and Provera)
- Estrogen plus progestin (brand name drugs include: Prempro, Femhrt, Climara Pro, and Activella among others)
According to the FDA, there are some risks for hormone therapy including possible blood clots, heart attacks, strokes, and breast cancer. Discuss these hormone therapy risks with your health care provider. The FDA also advises that hormone therapy should be used at the lowest helpful dose for the shortest time.
Does Medicare cover hormone therapy for menopause?
Original Medicare (Part A and Part B) only covers limited prescription drugs. Medicare Part A may cover prescription drugs you receive as an inpatient during a hospital stay or other inpatient facility. Medicare Part B may cover certain prescription drugs you receive as an outpatient, such as infusions and injections. Since you take most hormone therapy drugs at home, Medicare Part A and Part B will generally not cover hormone therapy for menopause.
To get Medicare coverage for hormone therapy, you generally need a Medicare Part D Prescription Drug Plan from a private insurance company. If you want to stay with Original Medicare, you can add a stand-alone Medicare Part D Prescription Drug Plan to cover hormone therapy. If you’d rather get all your Medicare coverage through one policy, you can sign up for a Medicare Advantage (Medicare Part C) Prescription Drug plan that covers your inpatient care, outpatient care, and prescription drugs such as hormone therapy.
Does my formulary cover hormone therapy for menopause?
To find out if your drug plan covers hormone therapy, consult the formulary, or list of covered drugs. Within each formulary, plans put medications into separate categories called tiers. Higher tiers typically list higher-priced medications, such as many name-brand drugs, while lower-priced drugs such as some generics tend to populate the lower tiers. Additionally, the formulary may change at any time. You will receive notice from your plan when necessary.
If your doctor prescribes a hormone therapy drug, check your plan’s formulary to see if the specific prescription drug is covered. If it’s not, ask your doctor for an alternative hormone therapy. As of 2017 the FDA lists over 20 brands of estrogen-only medicines for menopause, two options for progestin-only medicines for menopause, and seven brands of combination estrogen and progestin medicines for menopause. Keep in mind that your copayment, deductible, or other medication costs may differ among drug plans.
Need help finding a Medicare plan that covers hormone therapy for menopause?
I love to help people find Medicare plan options that fit their situations. If you are looking for coverage for hormone therapy, we can set up a telephone call whenever it’s convenient for you, or you can request information from me by email, if you follow the links at the end of this article. Why not take a quick look at available plans in your area right now? You can click the Compare Plans buttons on this page to do that.