Short story: how would an insurance company know if a prescription is for on/off-label use?
Hi all,
I have a silly question in regards to trt and insurance that I’m hoping someone who’s been through this could assist with. Forgive the stupid question as I have NEVER had any private health insurance coverage before. How does insurance know if a prescription is for off label use?
I have just started looking into my work drug plan coverage and test cyp is covered without prior authorization requirements. HCG is covered as well if used for fertility purposes Again without prior authorization required. My doctor is prescribing me test because I fall on the low end of the spectrum for my age and have numerous symptoms but by most standards considered normal (350 total test, 300-1000 scale). My fsh was also on the low end naturally (2 fsh,1-16 scale) so the doctor recommended hcg or clomid if cost is a concern. This means that the prescriptions are technically off-label use and optimization rather than therapy(based on numbers and not my symptoms). How would the insurance companies ever know if it’s off label if there is no prior authorization though? I would just like to cover my bases before I start HCG because I can’t afford the full cost of it without insurance. If I can’t get them to cover it I am going to say no to the clomid and just take the test. I just got insurance for the first time and am a little unsure of how this works and obviously can’t talk about cheating their system with them. I’m in Canada as well of that makes any difference.
Thanks bro’s
I’ll give you an example, anastrozole was developed for women with breast cancer, it was never intended for men, but is used off label for men on TRT and very high steroids dosages.
Your Total T score doesn’t mean this level is normal for you, it means there are outliers where this Total T levels will produce no symptoms. A lot of people, docs get caught up in the numbers, the symptoms are also equally important.
The newer studies are showing levels <550 ng/dl had a significant increase in the risk of cardiovascular disease. There are other studies showing cardiovascular/heart disease of men on TRT being kept at 332 ng/dL using patches, this puts a negative spotlight on TRT and docs are even more reluctant to prescribe it.
The clomid is there to cover your docs rear end and has a very very low chance of success, it’s just to make your doc look responsible in a world where TRT is stigmatized in our society.
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Thanks for the response and information.
I completely agree that what doctors use as a reference range is absolutely ridiculous. I have been complaining about symptoms (which I now know are low t) for years but that is disregarded because I’m just barely within the reference range. I was told that I’m just in the bottom 10%, I asked my doctor if he would want stocks in the bottom 10% roi range or see a doctor who finished bottom 10% of his class. This is the only reason I got a prescription at all.
Both TRT and HCG are used for treatment with men so it shouldn’t draw flags like a drug that is primarily used for a completely different purpose, correct? My insurance specified it covers HCG for fertility purposes so I should be golden because that’s what it’s prescribed for along side TRT if I’m not mistaken. I’m also covered for 100mg test a week which covers my prescription (80mg a week).
Right for “fertility purposes” as in when you are ready for children, but until then… Unless you have terrible testicular pain on TRT, HCG will probably only be covered when you say to your doctor my wife and I would like to have a child.
That may not be good enough, you need to get your levels into the therapeutic ranges 24/7 (550>) to benefit from treatment.
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I’ll have to talk to the doctor as to why that number was chosen because you’re right. it’s much lower of a dose than I was expecting to get, It seems like the low end is 100 with the higher end being 200. If I’m going to get something that puts me at the same levels I’m already at there isn’t really a point. My access to doctors who are comfortable with TRT is very limited, I had to go to another city.
Anyways, this has gotten off track from my initial inquiry into getting insurance to cover it. My plan says that I’m eligible for coverage on the test and hcg and neither are on the drug prior authorization list. if I really wanted to run the hcg I could say that I am trying to have kids, no? It is something that I am looking at in the nearish future. When I look at HCG in my insurance plans drug database it says I’m eligible and It says I have $20,000 lifetime coverage for fertility treatments, which is years worth of hcg. I don’t plan on staying with this job long term and would switch insurance companies once I transition to a new job anyways. I might as well use the coverage, no?
If the insurance company requires prior authorization (I know yours does not), they would want to know the diagnosis and the basis of the diagnosis.
If they do not require pre-authorization, the only way for them to know if it is off label would be to request documentation supporting the prescription, unlikely in your case, at least initially. At some point, they may question ongoing treatment, usually from a perspective of coverage denial.
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Thank you for the information! I figured as much but wanted to make sure!