Do I need a prior authorization to take HRT?

What is a prior authorization? 

A prior authorization (PA) is a certification or "permission" you must receive from your insurance before you can obtain certain services. While a number of services associated with your gender-affirming care can require a prior authorization, this will focus on situations where your HRT might require a PA.

While the exact terminology may vary from insurance carrier to carrier, there are generally two types of PA: clinical, and formulary management.

Clinical prior authorizations typically evaluate whether or not a medical regimen is safe and effective for the medical condition that it's being used to treat. Meanwhile, a formulary management PA is typically used to ensure you're using the most cost-effective medication available rather than jumping straight to more expensive alternatives.

Prior authorizations typically need to be re-certified annually.

Why might I need one? 

The reason you might need a prior authorization depends on which type of prior authorization you need. 

A clinical PA typically is intended to prove that the medication you're using is safe, effective, and, often, FDA-approved for the condition you're using it for.

For formulary management PAs, you're typically trying to prove that you've tried and failed more cost-effective options, or that those options are not safe and effective for you. 

For example, your insurance might cover injectable testosterone without much difficulty but require a PA for gel, which can be as much as 20 times the cost. Clinical prior authorizations may be intended to check for "cosmetic use," such as testosterone for bodybuilding versus for transition. Clinical PAs may also check to see if the medication regimen is appropriate for the age or sex it was prescribed to, which is where many insurers will attempt to evaluate most HRT treatments.

How do I get one? 

For formulary management prior authorizations, your provider will attempt to prove that you've either already used preferred alternatives and they were not effective for you for some reason. They will likely need to explain why non-preferred options will work for you when preferred options did not. 

Comorbid conditions, such as needle anxiety with injectable medications, can be used as justification for the use of more expensive alternatives. If you're new to your insurance, you may need to prove that you've tried alternatives in the past or prove that you are established on your existing regimen. The definition of a "trial" will vary based on your insurer's policies, but typically requires at least six months of consistent use of the preferred option.

For clinical PAs, your provider will be trying to show that the medication prescribed is safe and effective for the condition you're treating. Because the only diagnosis available in the ICD-10 is for gender dysphoria, this may turn into a gatekeeping experience for those that don't experience dysphoria, especially as many insurers will likely not understand the trans experience absent a diagnosis of dysphoria.

Many insurers follow WPATH Standards of Care and will likely also be looking for some variety of informed consent.

Some practical tips:

When working with your healthcare team…

• Communicate clearly: Make sure your provider understands your needs and goals.
• Utilize any available resources: Some healthcare providers and clinics have resources and staff specifically dedicated to helping patients navigate insurance issues.
• Get letters of support: Request letters from your healthcare providers explaining why HRT is medically necessary for you.

When dealing with your insurance company…

• Document everything: Keep a detailed record of all communications. Note the date and time of each conversation as well as who you spoke with.
• Ask questions: Don't hesitate to ask for detailed explanations if you don't understand something about your coverage.
• Advocate for yourself: Be persistent and advocate for your needs if you encounter resistance or delays. If you face discrimination or undue denial of coverage, consider seeking help from legal organizations that specialize in LGBTQ+ rights. You might want to reach out to your nearest LGBTQ+ center for guidance or connection to resources locally available. CenterLink’s LGBTQ+ Directory is a great place to start your research.

When troubleshooting common issues…

• Learn about the different types of insurance denials for trans healthcare and the next steps you can take to navigate an appeal.