Insurance Troubles With Testosterone

Insurance Troubles With Testosterone

We use testosterone replacement therapy (TRT) as part of a comprehensive Functional Medicine approach to improve the overall health of patients at our clinic in Tulsa, Oklahoma. We use several forms of testosterone including topical testosterone creams & gels, testosterone pellets (which are bioidentical hormones), and injections (such as Testosterone Cypionate or Testosterone Enanthate).

We have seen tremendous improvements in how our Tulsa patients feel in regards to their health, sleep, energy, sex drive, sexual performance, lean muscle mass, and many other effects.

Due to how much better most of our patients feel, we get a lot of referrals of people (men and women) who are looking to feel better and get healthier.

When new patients come in to our Tulsa Functional Medicine clinic we perform a physical exam, check a full history, and check labs. We need this information before we can appropriately implement any changes such as testosterone replacement therapy (TRT).

Some patients feel so bad that they want to get started right away. Others have been on testosterone therapy before and are anxious to get back on it. We often use the ADAM questionnaire to screen patients for testosterone deficiency. If these patients meet criteria then we may implement testosterone replacement therapy (TRT) right away.

ADAM (Androgen Deficiency in the Aging Male) questionnaire symptoms of low testosterone

1. Do you have a decrease in libido (sex drive)?
2. Do you have a lack of energy?
3. Do you have a decrease in strength and/or endurance?
4. Have you lost height?
5. Have you noticed a decreased “enjoyment of life”?
6. Are you sad and/or grumpy?
7. Are your erections less strong?
8. Have you noticed a recent deterioration in your ability to play sports?
9. Are you falling asleep after dinner?
10. Has there been a recent deterioration in your work performance?

If you Answer ‘Yes’ to number 1 or 7 OR ‘Yes’ to more than 3 questions, you may have low Testosterone.

Medical Necessity

In order for insurance to cover a given therapy or treatment they generally require medical necessity. Some insurances aren’t too picky about their definition of medical necessity in order to cover testosterone replacement therapy (TRT).

Many insurance companies require that a patient have documented 2 serum testosterone levels <300 in first morning samples. Testosterone levels are often highest in the morning.

The problem is that the medical literature clearly shows that men do better with higher levels of testosterone. Therefore, we don’t want to be less than 300, ever. Not at any time of day! From a functional medicine perspective, we aren’t interested in “normal.” We want OPTIMAL! You can listen to our podcast about Normal Lab Results.

Thus, we generally don’t wait for 2 first-morning testosterone results in order to initiate therapy. We may start therapy at the first visit based on the history and physical exam and then refine therapy based on labs and how the patient is doing at follow up.

You can listen to our Podcast on Testosterone & Whether Insurance Will Pay For It.

When we do initiate therapy early there is no way to get 2 first morning testosterone levels that would be deficient since they’ve already started testosterone therapy. If patients choose to not begin testosterone therapy then we have the option of checking a 2nd level in the morning and documenting low testosterone to insurance standards. There is a much better chance of getting testosterone replacement therapy (TRT) covered by insurance in these cases.

If you are concerned about getting their testosterone replacement therapy (TRT) covered by insurance you should keep a couple of things in mind. First, compounded topical testosterone is almost never covered by insurance. Second, if you choose pellet therapy, it isn’t going to be covered by insurance. The only therapy that gets consistent insurance coverage are testosterone injections (such as testosterone cypionate).

Testosterone Replacement Therapy (TRT) With Creams or Gels

There are some commercially available topical testosterones (axiron, testim, androgel, etc) but I have not seen good results with these in most cases. The concentration is so low that we don’t get the optimal levels for which we strive. When the goal is to get your testosterone level above 300 the commercially available stuff works.

These prescriptions are also incredibly expensive. Like, hundreds of dollars per month. Insurance may cover them but why are they so expensive. It increases the overall cost of healthcare which is already a major problem.

Testosterone Replacement Therapy (TRT) With Pellets

We’ve been using pellets for several years with excellent results. There are some commercially available, FDA approved testosterone pellets – Testopel. These pellets are 75mg and FDA approved for dosages of 150mg to 450mg. Again, we are looking for optimal and most of our patients look, feel, and perform their best when their testosterone levels range between 800mg to 1200mg. There is simply no way a dose of 450mg is going to get most patients into this range and keep them there for 3 to 6 months as recommended by Testopel.

We use compounded pellets. They are, as we always expect in any of our services, of the highest quality available. These pellets are not FDA approved. I’ve spoken about this on the podcast as well as other posts. Basically, this simply means that the medication and the specific dose have been tested and proven in clinical trials to be both safe and effective. In dealing with compounded medications, there is simply no way to test each specific dose and or combination and develop a study proving safety and effectiveness. It would be extremely cost prohibitive.

Again, our focus is optimal. Based on the medical literature, a level of around 1000 seems to be ideal. We don’t get these levels with commercially available Testopel nor testosterone creams and gels that are often covered by insurance.

Testosterone Replacement Therapy (TRT) With Injections

Injecting an oil of Testosterone Cypionate, Testosterone Enanthate, or Testosterone Propionate is a common form of Testosterone Replacement Therapy (TRT). These oil solutions are fairly inexpensive and quite cost-effective. Testosterone injections work quite well and provide good levels of serum testosterone when dosed appropriately.

If hypogonadism (low-testosterone due to inadequate testicular production) is documented as discussed previously then insurance may cover testosterone replacement with testosterone injections. The price for testosterone injections covered by insurance depends on your specific insurance plan and coverage.

I’ve seen patients pay as low as $10 per month for their testosterone prescription. However, they have to get their syringes and needles separately. Many times they end up pay $10-20 per month for their needles and syringes as well making their total about $20-30 per month.

If you elect to pay cash for your testosterone cypionate the price varies based on pharmacy. Some of the larger chains tend to be more expensive in our experience. It is common to find it for around $130 for a 10mL vial. You can certainly find it less expensive at some of the other pharmacies. For example, we charge $75 for a 10mL vial. That is the same price charged by NextGenRx. Needles and syringes are included in this price. Depending on dose, your monthly cost ends up being $15-30 month without having to deal with the headaches of insurance.

When I refer to the headaches of dealing with insurance I’m talking about a few things. A common roadblock is a Prior Authorization. This means that the insurance company is requiring submission of paperwork documenting low-testosterone and the need for replacement.

Think about looking at a flat tire on your car but not being able to get it replaced until you submit a special form to your spouse before they’ll let you get it fixed. If it needs to be fixed we should simply be able to fix it. The insurance companies do this because they require patients to have levels below what many patients need to look, feel, and perform well so they won’t pay for it.

Filling out paperwork, which often gets declined anyway, simply takes time and costs money all in hopes of getting insurance to pay for something that will save you very little money over simply paying cash. The time and money it takes to fill out these forms has to come from somewhere. At the end of the day, we have to hire more staff to fill out more paperwork which results in higher office visit fees. Please help us reduce these costs as much as possible!

Of course, you are welcome to try using your insurance to pay for any of your prescriptions. You pay for insurance and you might as well get as much benefit out of it as you can. We simply find that it often isn’t worth it in the case of testosterone.