My insurance is denying my medication...saying that GID is not a valid medical

[Shawn Sunshine]

Ok now SilverScript (under cvs caremark medicare part d) has decided to deny my prescription from my doctor. They have been approving all this time The Estrogen and the Spironolactone for the same reasons they are now denying the added micronized progesterone. My Doctor is requesting a formulary exception, because i had a letter before denying the medication , but now just got this letter in the mail that says this:

We denied coverage or payment under your medicare part D benefit for Progesterone:

We denied this request because in order for a drug to be considered for coverage it must be used for a medically accepted reason. Medically accepted reasons include uses which are approved by the FDA or are supported by certain medical references approved by medicare. The information provided by your Doctor/Provider/Prescriber (DIAGNOSIS OF GENDER IDENTITY DISORDER) did not meet the requirement of a medically accepted reason as defined above.

seriously?!?

So needless to say I am showing my letter to the doctor, she has not seen it yet as it just came.
The new one i mean with this info in it. It says we have the right to appeal...and I will for sure...i mean come on!!

They can't sit there and approve the other medicines and then all of the sudden say that my gender dysphoria is not valid now even though i am still getting approval for the other medicines?

Or can they?

[stephaniec]

I really don't know, I don't use it myself. The problem might be that a lot of doctors won't prescribe it for transgender because they don't believe it's worth the risks. I really don't know though

[Marly]

You might want to show that letter to an attorney.

[Cynobyte]

If you cant get any other help, try stroheckers pharmacy in oregon.  They are very good to talk to and may give you suggestions to try.  If all else fails then, they are hard to beat pricewise w/o insurance.   I have the same insurance too, but just gave up and pay cash.  I didnt like loosing my hair over stress;)

If you do call then, let us know if they had a solution..

[Shawn Sunshine]

I really don't know, I don't use it myself. The problem might be that a lot of doctors won't prescribe it for transgender because they don't believe it's worth the risks. I really don't know though

my doctor already prescribed it, been waiting 4 months for her to let me try it, she did research on her side with other doctors. Just frustrating to run into this hurdle when my body was ready for it (ie at the levels my doctor wanted on my other medicines)

[stephaniec]

my doctor already prescribed it, been waiting 4 months for her to let me try it, she did research on her side with other doctors. Just frustrating to run into this hurdle when my body was ready for it (ie at the levels my doctor wanted on my other medicines)

I really haven't the slightest knowledge of its effectiveness , but I wouldn't get into a frazzle about it because what I've read is it doesn't do much if anything, but I'm not a doctor , I only portray one on the internet.

[enigmaticrorschach]

omg! medicare is denying me to. luckily i have coupons. they arent telling me why though i havent called them yet.

[Shawn Sunshine]

well it can affect moods and breast growth, the naturally micronized is supposed to be helpful to some for moods. She is giving me a one month trial to see if it does anything at all for me.

[Devlyn]

Shawn, you used "gender dysphoria" which is the correct current terminology.  The email you quoted uses "Gender Identity Disorder" which is no longer used. Is that possibly the issue?

Hugs, Devlyn

[justjournalhonestly]

I just received a denial letter today as well, stating it is experimental and not FDA approved. Is this a new approach?

[JessicaH]

They are probably denying it because it is an off label use of the drug which any insurance company can deny.

[JLT1]

They are probably denying it because it is an off label use of the drug which any insurance company can deny.

Exactly.  The FDA has approved estrogen and a couple anti-androgens but not progesterone.

Sorry.

Hugs

Jen

[Shawn Sunshine]

Shawn, you used "gender dysphoria" which is the correct current terminology.  The email you quoted uses "Gender Identity Disorder" which is no longer used. Is that possibly the issue?

Hugs, Devlyn

I used the correct term..SO did my doctor....It appears silverscript is using the older termiNology

[Shawn Sunshine]

Exactly.  The FDA has approved estrogen and a couple anti-androgens but not progesterone.

Sorry.

Hugs

Jen

I see...Well that's possible...But the way they are wording it. That's what is the bigger issue for me.

[iKate]

They are probably denying it because it is an off label use of the drug which any insurance company can deny.

I disagree. They cover the estradiol which is also prescribed off label. Spiro is also prescribed off label as it is not really an anti androgen, that is only a side effect.

I think the real problem here is that they don't think that progesterone is a normal part of MTF hormone therapy.

[stephaniec]

Ditto, they're not going to pay out if they can get away with it. There is just too much disagreement among doctors on the effectiveness.

[iKate]

My insurance won't even cover it. I'm looking at $40 a month. However when I change my ID to female they will.

[Shawn Sunshine]

My insurance won't even cover it. I'm looking at $40 a month. However when I change my ID to female they will.

see i think thats crazy...yes cisgender women already have progesterone in a body...so im guessing the insurance thinks that since they started out with it...its medically neccesary to put it back (ie defeiency)

yet not transwomen?

[kelly_aus]

see i think thats crazy...yes cisgender women already have progesterone in a body...so im guessing the insurance thinks that since they started out with it...its medically neccesary to put it back (ie defeiency)

yet not transwomen?

There is peer reviewed medical evidence that estrogen and spiro have a beneficial effect for trans women.. The jury is still out on whether progesterone is of any benefit - and this may be part of the problem.

[Devlyn]

Here's what we have in the Wiki: https://www.susans.org/wiki/Progesterone