Medicare Coverage: Is Hormone Replacement Therapy Covered?

medicare coverage, hormone replacement therapy

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Hormone replacement therapy is the use of medications containing estrogen and progesterone to replace the hormones the body no longer makes after menopause. It is sometimes used to treat common menopausal symptoms, including hot flashes and vaginal discomfort.

Hormone replacement therapy has also been proven to prevent bone loss and reduce fractures in postmenopausal women.

There are two common types of hormone replacement therapy and each has different benefits:

  1. Estrogen-Therapy only therapy (ET). The estrogen hormone provides the most relief for menopausal symptoms. Most commonly, estrogen is used for women without a uterus due to a hysterectomy.
  2. Estrogen Plus Progesterone therapy (EPT). Progesterone hormones are added to ET for women with a uterus. Progesterone works to protect women from endometrial cancer.

Your prescription will come from your provider in one of two ways as there are two forms of hormone therapy:

  1. Localized (non-systemic). With this treatment, the medication comes in a cream, tablet, or ring. The drug only affects the area it touches.
  2. Systemic. With systemic treatments, the medications come as an oral tablet, injection, emulsion spray, patch, or gel. With systemic medications, the medicine enters the bloodstream and then affects all areas of the body.

Medicare coverage

Medicare coverage is limited for hormone therapy prescriptions. Under Medicare Part A, you will have prescription drug coverage under inpatient treatment at a hospital or inpatient facility. Medicare Part B may offer coverage for certain prescription drugs for outpatient situations. Since hormone therapy for menopause is typically done at home, Medicare will not cover hormone therapy in that situation.

In order to get Medicare to cover your hormone therapy, you will need to go through Medicare Part D prescription drug coverage. Refer to your plan’s formulary list to find out what is covered for you.


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The risks with hormone replacement therapy

In the largest clinical trial to date, a combination estrogen-progestin pill, Prempro, increased the risk of certain serious conditions, including:

  • Heart disease
  • Stroke
  • Blood clots
  • Breast cancer

Subsequent studies have suggested that these risks vary, depending on age. For example, women who begin hormone therapy more than 10 or 20 years from the onset of menopause or at age 60 or older are at greater risk of the above conditions. But if hormone therapy is started before the age of 60 or within 10 years of menopause, the benefits appear to outweigh the risks.

The risks of hormone therapy may also vary depending on whether estrogen is given alone or with progestin, the dose and type of estrogen, and other health factors such as your risks of heart and blood vessel (cardiovascular) disease, cancer risks, and family medical history.

All of these risks should be considered in deciding whether hormone therapy might be an option for you.

Who should consider hormone replacement therapy? 

Despite its health risks, systemic estrogen is still the most effective treatment for menopausal symptoms. The benefits of hormone therapy may outweigh the risks if you’re healthy and you:

  1. Experience moderate to severe hot flashes or other menopausal symptoms such as:
  • Mood swings
  • Depression
  • Irregular sleep patterns
  • Night sweats
  • Decreased sexual desire
  • Vaginal dryness
  • Nausea
  • Bladder infections
  1. Have lost bone mass and either can’t tolerate or aren’t benefiting from other treatments.
  2. Stopped having periods before age 40 (premature menopause) or lost normal function of your ovaries before age 40 (premature ovarian insufficiency).
  3. Experience early menopause, particularly if you have had your ovaries removed and prolong taking estrogen therapy until at least age 45, and have a higher risk of:
  • Osteoporosis
  • Heart disease
  • Premature death
  • Parkinson’s-like symptoms (Parkinsonism)
  • Anxiety or depression

For women who reach menopause prematurely, the protective benefits of hormone therapy usually outweigh the risks.

Your age, type of menopause, and time since menopause play significant roles in the risks associated with hormone therapy. Talk to your doctor and healthcare provider about your options and the risks involved before going forward with any hormone therapy treatment.

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