I am a 44 year old male who has always been active, eat healthy and workout regularly. I have extremely low total T of 174 and free T of 3.4 yet my endocrinologist won’t start me on TRT. The standard range for total Testosterone is at below 123 for low testosterone for the lab. I feel like I would have to be in a coma to be below 123. I This is the 3rd round of testing in which both my total and free were very low and I have every low T symptom. I’ve had a pituitary MRI which came back normal. It looks like a never ending cycle of no action and more continuing blood work with my endo. I feel like my best chance to start TRT is with a TRT clinic but I don’t know if they accept insurance and what the costs typically are if they don’t. I know my prescription insurance covers testosterone cypionate injections with a prior authorization from a Dr but I don’t know about the Dr visits to the TRT clinic and bloodwork there. My blood work has been completely covered with my endo for the past 2 years. Does anyone know how insurance & costs associated work with TRT clinics?
The TRT clinics that know what they are doing will not accept insurance. You have to pay from your pocket to get a quality care.
Where do you live?
I had to go through a few endos to get a script. Now I found a urologist who does trt.
Unless you are below 123, your endocrinologist cannot diagnose you with hypogonadism. According to them, you are “normal” and within normal range. You have, by definition, “sub clinical hypogonadism”. If your doctor submits this to your insurance a diagnosis is needed and for you to be covered by your insurance it must be hypogonadism. If you doctor does that, it is fraud. If the insurance company requests supporting documentation, they will deny treatment, based on your lab value, as “not medically necessary”. If the doctor submits enough of these claims they may report him/her to the state medical board.
Keep in mind insurance companies are in business to collect premiums, not pay claims. Generally, they will pay for tests and deny, or regulate/dictate treatments. For example, the range for total testosterone with Quest is 250-1100ng/dL, a huge range. If you are 255, you are within normal. That bottom number used to be 350, by the way. I was told that Blue Cross played a role in getting that number reduced some time ago. They will also require labs to be drawn prior to 9am, when levels are higher, and some will require two or three samples, all must be below range for treatment to be allowed.
Plus, often, they will deny tests such as estradiol (not important because you are a man) and others typically evaluated for thorough TRT management. Doctors within the managed care networks are handcuffed and they don’t like it any more than you. It’s just the way it is. “Managed care” does not mean care is managed by your doctor.
Therefore, TRT specialty clinics operate outside insurance control. Most patients seen are within lab range, “normal” but with low testosterone symptoms. Patients below the range are often seen because insurance companies will not allow necessary dosing to adequately treat symptoms. TRT clinics often use a concierge format or fee structure. Costs are typically from $1000-2000 a year including prescriptions, labs and visits. You may pay a few hundred to get started.
I have VERY GOOD insurance and was covered after being diagnosed with hypogonadism. My insurance required two separate tests before 10am and total test had to be under 250ng/dl (or maybe 300, I’d have to look it back up in my insurance documentation). Here’s the deal though, at a T Clinic you have to go in office every week for an injection (or if they’re stupid you’ll be going in every two weeks), meaning you’ll be paying whatever your copay is every week. A T Clinic for my insurance is considered a “specialist” so I pay the specialist co pay of $45 every week. Between that and scheduling an appointment and visiting the office every week, which was a waste of time and annoying, receiving one large dose a week instead of splitting it up to keep levels more consistent, being “just a number” to the clinic, and the clinic always running late on appointments, I’m now with a private T (tele) clinic. Pricing is actually a little less with the private clinic paying out of pocket and you don’t have big brother (insurance) controlling your treatment.
To answer your question on insurance and bloods, I pay 10% co-insurance on them; but, your insurance has a negotiated rate that is considerably cheaper than paying out of pocket so do have your bloods billed to your insurance if going through a t clinic. For example, my initial bloods at the T Clinic were about $750, insurance negotiated rate was $76, I paid $7.60 (10% coinsurance). Some insurance companies cover bloods only after you meet your deductible.
I’ve had no problem going through my PCP. I originally came in at 303 ng/dL with symptoms and he diagnosed me and the insurance didn’t give me any trouble. He also mentioned at the time that if they did refuse to pay, he’d still work with me and I could pay out of pocket and go with Test Cypionate or Test Enanthate which would be more affordable but it never came to that. I pay a $10 copay for my T every month and a $20 copay for the doctor visit every 6 months or so. I had a modest charge for the labs once, $175 or so if I recall correctly, probably because I use the Quest Diagnostics lab near my house rather than drive across town to use the Kaiser Permanente lab.
You could skip a night of sleep before your labs the next morning. At 174 ng/dL you likely are suffering. I was at 370 ng/dL. If you skip sleep you will probably test lower. Having a few drinks will lower it even further.
Not an ideal solution, but if you can’t afford private, this might get you there.
That is true in some cases, but not all. Many will allow self injections so you don’t have to keep going in. Those that force in office shots are just after the money that comes with a visit every week or (god forbid) every other week IMO.
To answer the original question:
Almost none of them accept insurance directly. The guidelines for what qualifies for TRT, according to the insurance companies, is just so low that it doesn’t make sense for them to add in the inevitable hassle of getting denied over and over by the insurance company.
There are places that will fill out the insurance reimbursement paperwork for you for a small fee (like, $15), then you can submit that as a claim to your insurance and get them to reimburse you for whatever they will cover. I’m in the process of doing this now. Defy Medical offers this for example. Best case… you might get insurance to pay you back for lab work and the visit, but not likely they’ll pay for the meds unless you truly are low enough for TRT by their standards. That still can help quite a bit though.
It’s an option that has worked for some to at least reduce the overall cost. Otherwise… you’re down to just paying cash.
Additionally, if you can get a script, but insurance won’t cover it, you could buy a GoodRx subscription for like $6 a month. You can get a 10 mL bottle of Test C 200 mg/mL with GoodRx for $15-$20. If that bottle lasts about 3 months, you would have $18 in GoodRx subscription fees and $20 for the bottle of Test. Not too bad IMO.
Edit: Just checked and the Testosterone coupon does not require a subscription, but the script is for 2 mL not 10 mL. $15 for 2 mL equates to $75 for 10 mL (since the coupon is free).
This may be the lab range, but it has nothing to do with normal reference ranges, the problem here is the lab company, reference ranges are 264-916 per Labcorp and <300 qualifies you for TRT according to the endocrine society guidelines and all that’s needed is a doc that reads guidelines.
Your probably don’t want this endo prescribing TRT anyways, he doesn’t sound very informed and he has probably never read the endocrine guidelines. TRT clinics typically do not take insurance, if you ran a business you wouldn’t want the headache of dealing with insurance companies because it limits profitability.
The profit margins are insanely high for TRT can be as high as 95%. If you’re a business dealing with insurance companies, than you deal with the auditors who are always looking for an excuse to refuse reimbursement for services if the person doesn’t qualify for treatment, but because these TRT clinics are a cash only business the sky’s the limit on how much they can charge and the person will pay it and no insurance BS.
The problem here is your endo doesn’t know any better, anyone who thinks 123 ng/dL is normal doesn’t have their head in the hormone game. Go to Labcorp and get testing, then when your levels are below range, a doctor will prescribe TRT. It’s bullshit that you can go to another region and the reference ranges are completely different.
This is what you get when there are no standards, it confuses docs because the lab ranges don’t match up with normal ranges defined by these institutions. They guidelines state TRT can be prescribed as high as 345 ng/dL and the AUA guidelines state if there is a medical benefit, TRT can be prescribed.
My Dr gave in to my request when I was at 295 and the insurance went along with it without question. That was 6 yrs ago so I don’t know if things have changed. Probably more depends on your particular insurance.
Supposedly, it can be diagnosed with borderline low T based on symptoms but I’m sure it’s rare to get a doc to actually do it and for insurance to pay for it.