Does Medicare Cover Low-T treatment? 

Testosterone, the male sex hormone, is essential to sexual development in males. The American Urology Association (AUA) has historically identified low blood testosterone as less than 300 nanograms per deciliter (ng/dL). The condition is known as Testosterone Deficiency Syndrome (TD) or Low Testosterone (Low-T).

Symptoms and treatment

When you have Low-T, you may experience a diminished sex drive, fatigue, low lean muscle mass, depression, irritability and erectile dysfunction. Since these symptoms can arise from many other health conditions, your doctor may order lab work, an MRI, a bone density test and more. A thorough assessment takes into account test results combined with a physical exam and a review of your health history.

Many factors may cause Low-T, including obesity. Healthcare providers may suggest starting with weight loss and physical activity before moving onto Testosterone Therapy (TT). There are five main approaches to TT: transdermal (topical gels, liquids, creams or patches), injections (under your skin or in your muscle), oral medication (released through patch in your mouth), intra-nasal (gel pumped into your nose) and pellets (placed under your skin).  

Medicare Part D coverage for low testosterone

Look for testosterone prescription medication coverage details in your Medicare prescription drug plan (Part D). If you get your benefits through Original Medicare, you probably purchased a prescription drug policy during your Initial Enrollment Period. If not, sign up during Open Enrollment. 

The Part D formulary is the plan’s list of covered medications. Your cost will be tied to the tier your plan assigns to the drug. Drugs on lower tiers, generic drugs, are lower priced than drugs on higher tiers that include brand and specialty drugs. Your plan provides cost-sharing information. 

Some beneficiaries have a Medicare Advantage Prescription Drug (MAPD) plan that includes Part A, Part B and Part D. Many MA plans also cover over-the-counter medications and other drugstore products.

Medicare Part B

There are specific drugs that fall under Part B benefits, including injections your doctor administers in an outpatient setting. Under special circumstances, Medicare may cover drugs you get in a hospital outpatient setting. Part B does not include self-administered drugs. 

Part B also covers medically necessary laboratory tests for clinical diagnosis. With your doctor’s authorization, Part B covers blood tests, urinalysis and other lab work. Covered diagnostic non-laboratory tests include MRIs, EKGs, CT scans and X-rays.

Part B benefits require an annual deductible, which changes each year. Once you meet the deductible, your cost is 20% of the Medicare-approved amount. To ensure the full benefit applies, check that your healthcare providers and facilities participate with the Medicare program. If you have Medicare Advantage, you will get the most benefits using providers and suppliers in the plan’s network. 

Getting support

If you receive a Low-T diagnosis, gathering research about the condition can help you prepare for a discussion with your doctor about the treatment most suitable for you. Sources include the National Institutes of Health (NIH), the Food and Drug Administration (FDA) and the Urology Care Foundation.

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