Hormone Replacement Therapy (HRT) is a type of treatment prescribed to women experiencing menopause symptoms. HRT is meant to relieve symptoms like hot flashes, mood swings, night sweats, and even osteoporosis. While HRT is not recommended for every woman, your doctor may suggest it as a treatment option. If so, it’s important that you know how Medicare will cover it.
How HRT works
The purpose of HRT is not to stop or prevent menopause. Instead, HRT simply lessens the effects of the symptoms brought on by menopause. HRT does this by replacing the hormones in your body that are lost due to menopause.
There are several different types and dosage recommendations of HRT available, so your doctor will recommend a specific plan based on your situation. For example, if you’re at the beginning stages of menopause, your doctor may start you on a low dose of HRT, and later increase the dosage once your menopause has progressed.
In addition to varying dosages, there are several ways of administering HRT and versions of HRT hormones. HRT comes in the form of tablets, patches, creams, and more. Also, some HRT treatment plans include both oestrogen and progestogen or one of the other.
Which part of Medicare covers HRT
Medicare Part B covers outpatient services such as doctor visits, durable medical equipment, lab work, and more. Part B also covers certain prescription medications that are administered to you by a medical professional or medical equipment. While Medicare Part B covers some prescription medications, Part D provides most of your drug coverage.
Most HRT drugs will be subject to Part D coverage. Some forms of HRT drugs may be subject to Part B coverage, such as a vaginal ring. If your HRT medication is in the form of a pill, gel, patch, or another form you would administer yourself, you will look to your Part D plan for coverage.
How Part D coverage works
Part D plans are provided in the form of a standalone plan or as a built-in part of a Medicare Advantage plan – either way, both types of Part D plans have the same structure. Part D plans have a premium, deductible, set copays and coinsurance for each drug tier, spending caps for each payment level, a formulary of covered drugs, and drug restrictions. However, each of these characteristics can vary by plan.
In 2020, the highest a Part D deductible can be is $435. Generally, you will have to meet this deductible before your Part D plan pays anything for your prescriptions. Once you’ve paid your plan’s deductible in full, your plan will cover a portion of your prescription costs, leaving you with either a copay or coinsurance. Depending on the tier your drug falls in, your copay/coinsurance could be minimal, or much higher.
For example, if you’re prescribed Estradiol, a tablet form of HRT, you may only have a $5 copay after the deductible, whereas you may have a $40 copay for a Menest prescription. This is because these two specific drugs may fall under different drug tiers within your plan. A tier 4 HRT drug will cost more than a tier 2 drug. But again, prices will vary by plan, medication, tier, pharmacy, and more.
The Part D coverage gap and catastrophic coverage
After you and your plan have paid a total of $4,020 in 2020, you will move into the coverage gap where your copay or coinsurance may increase or decrease. In the coverage gap, you are capped at a 25% coinsurance. Therefore, if your costs prior to the coverage gap were more than 25% of the total drug costs, your out-of-pocket costs will decrease during the coverage gap stage, or vice versa.
Depending on the type of HRT you use and what other medications you are taking, you may reach the coverage gap and then some. Fortunately, all Part D drug plans have a catastrophic limit that kicks in eventually. After you and your plan have spent a total of $6,350 for the entire year, you will move into catastrophic coverage where your copays and coinsurance will decrease much more. During this final stage, you will either pay a 5% coinsurance or a copay of $3.60 or $8.95, depending on the type of drug.
As you can see, whether Medicare will cover your HRT or not all depends on the Part D plan you have and the type of medication you receive. If you start HRT prior to beginning Medicare, be sure to find a Part D plan covering all or most of your medications – this will likely be the most cost-effective plan.
If you already have a Part D plan when you start HRT, work with your doctor to find a medication that will both work for your symptoms that is also covered under your current plan. Remember, you can also change Part D plans each year during the Annual Election Period.