Policy ID: S-32-011 Show
Section: Surgery Effective Date: February 01, 2020 Revised Date: January 12, 2022 Revision Effective Date: March 01, 2022 Last Reviewed: January 20, 2022 Applies To: Commercial and Medicaid Expansion DescriptionHormone replacement therapy (HRT) using formulas in subcutaneously implantable pellet form is an alternative to hormone therapy by injection or oral ingestion. Pellets are implanted in the physician's office and release their contents over a period of months. CriteriaCoverage is subject to the specific terms of the member’s benefit plan. Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website. Subcutaneous testosterone pellets may be considered medically necessary when there is documented failure or contraindication to other topical, oral, and injectable HRT and ONE of the following conditions:
Subcutaneous testosterone pellets not meeting the criteria as indicated in this policy are considered experimental/investigational. Procedure CodesSubcutaneous testosterone pellets as a treatment for menopausal symptoms and/or reduced libido are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. Subcutaneous pellets composed of estradiol, estrogen, or estrogen in combination with testosterone are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. Procedure CodesDiagnosis CodesCovered diagnosis codes for 11980 and S0189
Professional Statements and Societal Positions GuidelinesNot Applicable ND Committee ReviewInternal Medical Policy Committee 1-22-2020 adopting policy for diagnosis coding Internal Medical Policy Committee 7-22-2020 Annual review, no clinical content change Internal Medical Policy Committee 7-22-2021 Annual review, no clinical content change Internal Medical Policy Committee 1-20-2022 Updated experimental/investigational statements DisclaimerCurrent medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. Policy ID: S-32-010 Section: Surgery Effective Date: February 01, 2020 Revised Date: July 07, 2021 Revision Effective Date: September 01, 2021 Last Reviewed: July 22, 2021 Archived Date: February 28, 2022 Applies To: Commercial and Medicaid Expansion DescriptionHormone replacement therapy (HRT) using formulas in subcutaneously implantable pellet form is an alternative to hormone therapy by injection or oral ingestion. Pellets are implanted in the physician's office and release their contents over a period of months. CriteriaCoverage is subject to the specific terms of the member’s benefit plan. Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website. Subcutaneous testosterone pellets may be considered medically necessary when there is documented failure or contraindication to other topical, oral, and injectable HRT and ONE of the following conditions:
Procedure CodesSubcutaneous testosterone pellets as a treatment for menopausal symptoms and/or reduced libido or any other indications not listed above are considered experimental/investigational and therefore non-covered. Scientific evidence of safety and efficacy has not been proven. Subcutaneous pellets composed of estradiol, estrogen, or estrogen in combination with testosterone are considered experimental/investigational and, therefore, non-covered. Scientific evidence of safety and efficacy has not been proven. Procedure CodesDiagnosis CodesCovered diagnosis codes for 11980 and S0189
Professional Statements and Societal Positions GuidelinesNot Applicable ND Committee ReviewInternal Medical Policy Committee 1-22-2020 adopting policy for diagnosis coding Internal Medical Policy Committee 7-22-2020 Annual review, no clinical content change Internal Medical Policy Committee 7-22-2021 Annual review, no clinical content change DisclaimerCurrent medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically. Do you have to pay for hormone therapy?Monthly prescription costs for oral HRT run $130 to $240 per month, for an annual fee of $1560 to $2440. But, because most insurance companies pay for HRT pills, most people only see their prescription co-pay costs, which typically average $30 per month or $360 per year.
How do I get approved for HRT?To start HRT, you will need 1 referral letter from a licensed mental health provider that addresses the WPATH Standards of Care guidelines. What are my next steps to start HRT? 1. Meet with your licensed mental health provider to obtain a referral letter and sign a Release of Information Form for them.
How much does HRT cost FTM?On average, hormone replacement therapy (HRT) for gender affirmation can cost anywhere from $30-$100 a month for individuals without health insurance.
Does United Healthcare cover hormones?Hormones injected by a medical provider (for example hormones injected during an office visit) are covered by the medical plan. Benefits for these injections vary depending on the plan design. Oral and self-injected hormones from a pharmacy are not covered under the medical plan.
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