Testosterone replacement therapy (TRT) is a treatment method used to increase testosterone levels in individuals diagnosed with low production of the hormone. This therapy is available in several forms, including injections, patches, gels, and implanted pellets. Whether Medicare will cover the cost of TRT is not simple, as coverage depends heavily on the specific medical reason for the treatment and the method by which the therapy is delivered.
Understanding the structure of your Medicare plan and the underlying clinical requirements is the first step in determining your potential out-of-pocket costs. Medicare benefits are divided into different parts, and the specific part covering your TRT depends on whether you administer the medication yourself or receive it in a clinical setting.
Establishing Medical Necessity for Coverage
Medicare coverage for Testosterone Replacement Therapy relies on a determination of medical necessity. The treatment must be prescribed to address a documented medical condition, such as symptomatic hypogonadism, which results from a disorder of the testicles, pituitary gland, or brain. Treatment for a naturally occurring, age-related decline in testosterone, often termed “late-onset hypogonadism,” is generally not considered medically necessary and is typically not covered. Medicare will also not cover TRT for “idiopathic hypogonadism,” which is a low testosterone level with no clear underlying cause.
To establish medical necessity, a patient must present with consistent symptoms, such as decreased libido, fatigue, or erectile dysfunction, alongside unequivocally low serum testosterone levels. Diagnostic testing requires a blood sample taken in the early morning to confirm a total testosterone level below the lower limit of the normal range (often 200 to 400 ng/dL). This low level must usually be confirmed with a repeat test on a separate occasion. Coverage may also be denied if certain contraindications are present, such as a hematocrit blood test result over 48% or a recent history of heart attack or stroke.
Coverage for Prescription TRT (Medicare Part D)
Testosterone Replacement Therapy that is self-administered at home falls under Medicare Part D, which is the prescription drug coverage. This category includes topical gels, patches, oral treatments, and self-injected solutions that are filled at a pharmacy. Since private insurance companies offer Part D plans, coverage for a specific testosterone medication depends on whether the drug is listed on the plan’s formulary.
Every Part D formulary organizes drugs into different tiers, which determines the patient’s out-of-pocket cost; generic versions typically cost less than brand-name drugs. Even if a testosterone product is on the formulary, the plan may require a step therapy protocol, meaning the beneficiary must try a lower-cost, preferred drug first. Many Part D plans also require a Prior Authorization (PA) for testosterone therapy, where the doctor must submit documentation proving the treatment meets the plan’s medical necessity criteria before coverage is approved.
Coverage for Provider-Administered TRT (Medicare Part B)
When a testosterone treatment is administered by a healthcare professional in an outpatient setting, such as a doctor’s office or clinic, coverage is typically handled by Medicare Part B. This usually applies to injectable forms of testosterone given in-office, as well as the insertion of long-acting testosterone pellets. Part B also covers the necessary doctor visits and laboratory services, like the required diagnostic blood work, related to the treatment.
After the annual Part B deductible is met, the beneficiary is responsible for a 20% coinsurance of the Medicare-approved amount for the office visit and the administered drug. Medicare pays the remaining 80% for covered services. This cost-sharing structure applies to the treatment itself, as well as any ongoing monitoring and follow-up care provided in the clinical setting.
Calculating Out-of-Pocket Costs
The total out-of-pocket cost for TRT is a combination of deductibles, copayments, and coinsurance across both Part B and Part D. For Part B services, after the annual deductible is satisfied, the patient must pay 20% of the cost for each in-office injection or pellet insertion. For Part D, costs vary significantly based on the plan’s formulary, but generally include an annual deductible, followed by a copayment or coinsurance for each prescription refill. As of 2025, Part D plans feature a $2,000 annual out-of-pocket cap for covered medications, offering a limit to the drug costs a beneficiary must pay in a year.
Supplemental coverage can significantly reduce these financial burdens, though the specifics depend on the type of plan. A Medigap policy works with Original Medicare (Parts A and B) and can cover the Part B 20% coinsurance, substantially reducing the cost of provider-administered TRT. Medicare Advantage plans (Part C) must cover the same services as Original Medicare, but they may have different copayments, deductibles, and formularies. Beneficiaries in a Part C plan should check their specific plan documents for the exact cost-sharing requirements for both medical and prescription components of their testosterone therapy.