Medicare does cover hormone replacement therapy in most cases, but the type of coverage depends on what form of HRT you’re using and why it’s prescribed. Oral and topical hormones typically fall under Part D (prescription drug coverage), while injectable or implantable forms may be covered under Part B (medical coverage). The specifics vary by plan, and some forms of HRT are harder to get covered than others.
How Part D Covers HRT for Menopause
If you’re prescribed estrogen, progesterone, or a combination hormone therapy for menopause symptoms, that prescription generally falls under Medicare Part D. Your doctor needs to confirm the therapy is medically necessary for your symptoms, which is the standard requirement for Part D drug coverage.
Some Part D plans require prior authorization for HRT, meaning the plan must approve coverage before you fill your prescription. This adds a step but doesn’t mean you’ll be denied. Your doctor’s office typically handles the authorization process. The specific copay or coinsurance you’ll owe depends on which tier your medication falls on in your plan’s formulary. Generic estradiol tablets or patches tend to land on lower, cheaper tiers, while brand-name options cost more.
A significant change for 2025: Part D now caps annual out-of-pocket spending at $2,000. Once you hit that limit, you pay nothing for covered prescriptions for the rest of the year. For people on higher-cost HRT formulations, this cap can make a real difference.
Testosterone Replacement Under Medicare
Testosterone therapy for men with clinically low levels is covered, but Medicare sets a higher bar for proving medical necessity. Coverage requires a formal diagnosis of hypogonadism based on at least two separate fasting blood draws taken before 10 a.m. on different days, using the same lab. If your total testosterone comes back below 280 ng/dL, further testing is warranted with additional blood draws at least one month apart.
For men whose levels fall in the 200 to 300 ng/dL range and who also have obesity or type 2 diabetes (conditions that affect how testosterone binds in the blood), the plan may require a more specific test measuring free testosterone. If that number comes back normal, testosterone therapy won’t be covered because the clinical need isn’t established.
Testosterone gels, patches, and oral formulations go through Part D. Injectable testosterone administered in a doctor’s office can be billed under Part B. Implantable testosterone pellets have historically been covered under Part B for FDA-approved uses, with a maximum of six pellets per implantation session.
Gender-Affirming Hormone Therapy
Medicare has no national policy that either approves or denies coverage for gender-affirming hormone therapy. In 2016, CMS declined to issue a National Coverage Determination for gender dysphoria treatments, explicitly noting that this decision was not a national non-coverage ruling. Instead, coverage decisions are made locally by Medicare Administrative Contractors (MACs) on a case-by-case basis.
What this means in practice is that your coverage depends on where you live and which MAC handles your region’s claims. Some MACs have approved hormone therapy for gender dysphoria when a provider documents medical necessity. Others have been less consistent. If your initial claim is denied, you have the right to appeal, and many denials are overturned at the appeals level. Working with a provider experienced in submitting these claims can improve your chances of approval on the first try.
Compounded and Bioidentical Hormones
Compounded hormones, the custom-mixed formulations often marketed as “bioidentical hormone replacement therapy” from specialty pharmacies, have limited and complicated coverage under Medicare. Part D can only cover the portion of a compounded prescription that contains ingredients meeting the definition of a Part D drug. If your compound contains ingredients that are just bulk pharmaceutical powders with no FDA-approved drug equivalent, those components aren’t covered at all.
In practice, this means a compounded cream containing estradiol (an FDA-approved ingredient) might be partially covered, but the total cost billed to Part D can only reflect the covered ingredient, not the full compound. Many compounding pharmacies don’t bill Medicare at all because of this complexity, leaving you to pay out of pocket. If cost is a concern, ask your doctor whether an FDA-approved version of your hormone therapy exists. In many cases, commercially manufactured bioidentical hormones like estradiol patches or micronized progesterone capsules are available, fully covered under Part D, and pharmacologically identical to what a compounding pharmacy would mix.
Medicare Advantage vs. Original Medicare
If you’re on a Medicare Advantage plan (Part C), your HRT coverage works slightly differently in structure but not in substance. Most Advantage plans bundle Part D drug coverage into the plan, so you don’t need a separate prescription drug plan. The same medical necessity rules apply, and your plan must cover at least what Original Medicare covers.
Where Advantage plans can differ is in formulary details. One Advantage plan might place your specific estrogen patch on a preferred tier with a $20 copay, while another puts it on a higher tier at $47. Before enrolling or during open enrollment, check whether your current HRT medication is on the plan’s formulary and what tier it falls on. You can do this through the plan’s online drug lookup tool or by calling the plan directly.
Reducing Your Out-of-Pocket Costs
Even with coverage, HRT costs can add up over years of use. A few strategies can help. First, ask your doctor about generic options. Generic estradiol, medroxyprogesterone, and testosterone formulations are widely available and often fall on the lowest Part D cost-sharing tiers. Second, if you qualify for Medicare’s Extra Help program (also called the Low-Income Subsidy), your Part D premiums, deductibles, and copays drop significantly. You can qualify with an income up to 150% of the federal poverty level.
Third, take advantage of the $2,000 annual out-of-pocket cap on Part D. If you take multiple prescriptions alongside HRT, all your Part D spending counts toward that cap. Once you reach it, your covered drugs cost nothing for the remainder of the calendar year. And finally, if your plan requires prior authorization and denies your specific medication, ask your doctor to submit a formulary exception request for a medically necessary alternative. Plans are required to review these requests and respond within set timeframes.