Does AHCCCS cover hormone replacement therapy? - Elite Hormone Therapy

AHCCCS is Arizona's Medicaid agency that provides health insurance coverage for low-income residents. AHCCCS covers medically necessary services, including hormone replacement therapy (HRT), for eligible members. To receive AHCCCS coverage for HRT, the therapy must be deemed medically necessary by your doctor. Reasons why HRT may be considered medically necessary include:

• Treating symptoms of menopause such as hot flashes, night sweats, vaginal dryness
• Treating hypogonadism or low sex hormone levels
• Preventing osteoporosis or bone loss
• Transgender hormone therapy to assist with gender transition

Coverage and reimbursement for HRT under AHCCCS depends on several factors:

• Member eligibility - You must qualify for and be actively enrolled in AHCCCS. Eligibility is based on income, household size, disability status, and other criteria
• Medical necessity - Your doctor will need to demonstrate that HRT is medically necessary for your condition through proper diagnosis and documentation
• Prior authorization - For some forms of HRT, prior approval may be required from AHCCCS before treatment can begin
• Provider and pharmacy - The HRT services, doctor, or pharmacy must be in the AHCCCS provider network

If approved for coverage, AHCCCS can cover the costs of:

• Hormone medications - Testosterone, estrogen, progesterone prescribed by your doctor
• Lab testing - Blood work to monitor hormone levels
• Doctor visits - Appointments related to overseeing and managing HRT
• Administration - Injections or pellet insertions to administer hormone therapy

What Types of HRT Does AHCCCS Cover? There are several types of FDA-approved hormone replacement therapy that AHCCCS can potentially cover:

• Estrogen
  • Premarin, Estrace - pill, cream, vaginal ring or skin patch forms
• Progesterone
  • Prometrium - pill or vaginal gel
• Testosterone
  • AndroGel, Testim - skin gels/creams
  • Testopel - hormone pellet implants
• Human growth hormone - Omnitrope, Genotropin - injections for confirmed growth hormone deficiency

Limitations and Exclusions

• Off-label hormone use not approved by the FDA is typically not covered
• Over-the-counter hormone products like progesterone creams
• Alternative hormone therapies including compounded bioidentical hormones
• Fertility treatments/procedures involving hormones

Elite Hormone Therapy in Phoenix, AZ has extensive experience working with AHCCCS members to obtain coverage and provide individualized hormone replacement therapy treatment tailored to your health needs. Schedule a consultation today to determine if our therapies are right for you! The Bottom Line In summary, AHCCCS can potentially cover FDA-approved forms of medically necessary hormone replacement therapy including medications, testing, doctor visits and administration costs. Coverage depends on the specifics of your case, including eligibility, medical need, prior approval and using in-network providers. Speak to your doctor and AHCCCS representative about your options.