Hey y'all, I'm writing this post because recently (today) I heard back from my health insurance about the coverage of my T. I recently got insurance through the ACA which began Jan 1. I've been on T for two years prior to that date. I have never been on injections because I'm notorious for passing out every time I had to get bloodwork or even a shot. So when starting T, my doctor told me he'd feel the best if we started on gel. I was getting my T from Stroheckers in Oregon as many of you have heard of I'm sure. But I was on a lower dosage and it cost me about $120 a month. Now I am on triple the dosage that I had when I paid for it at Stroheckers. My insurance was covering Androgel from a local pharmacy up until a week ago when I tried to refill it, the pharmacist told me I needed prior authorization to continue coverage. So I contacted my dr who contacted the insurance, ect. And after a week of being without T, I called my insurance and they said they denied my prior authorization because I hadn't done the injections. So tomorrow I am going to call my dr again and tell him to appeal it and tell the insurance that brand name is necessary because there aren't any generic T creams or gels. According to my insurance medication list, the Androgel DOESN'T involve step therapy, so it isn't necessary that I try both types of injections before they'll cover it but when I spoke to a healthcare rep. they told me if my doctor said that I needed brand name and no generic substitutes were good options for me they'd cover it. But he didn't say that on his fax when I called to ask if they had. So I guess my questions are: What retrogression will I face if I can't get my T for another week or however long an appeal takes? and Does anyone know what my dr needs to say for the reasons injections aren't good for me? I mean he knows I frequently pass out for bloodwork but there isn't any specific medical documents backing it up so can he just say I can't do needles so gel is necessary? I've been a week without T and I feel like I'm losing my mind please help guys, it will be much appreciated to get any insight regarding the matter. :/

A couple weeks or even a month won't make a lot of difference at all. Well, other than mentally. That part is depressing.

Quote from: LordKAT on June 10, 2014, 12:05:19 AM
A couple weeks or even a month won't make a lot of difference at all. Well, other than mentally. That part is depressing.

A month to six weeks would seem to be an upper limit before undesirable things start happening, given that you have been on T for an extended period of time. 

I had a similar problem with my insurance and E-patches.  I developed an allergy to the adhesive.  A couple pictures of me pulling the patch off along with the skin underneath solved that.  For you, it would be a statement from a Dr talking about you passing out when injections are involved.  You need that statement.

Jen
 

thanks guys! an update i went to the dr today to get a rx for the inject-able and he did but when i went to the pharmacy to fill it, they said it wasn't covered and called my insurance. my insurance told the pharmacist that i was inactive and didn't have insurance with them.... so they illegally dropped me? its an obamacare plan and i believe it was made a law that they can't drop me at any time if i get really sick or anything? please help! I will definitely be contacting the UCLA for this matter~!

Sounds like good old discrimination to me, but maybe they had you confused with someone else with a similar name/close plan number. Definitely report them after checking into the matter by calling the insurance company yourself. Could it be the pharmacy discriminating against you? I've had that happen to me and changed pharmacies, no problems since. I did however report the pharmacy and individuals to the correct places. They would claim the doctor never sent the prescription, or that they were having a shortage when I hand delivered the paper prescription, or that somehow my insurance wouldn't cover the generic. Boy did they have a time explaining that to the insurance agent I had on my cellphone who was looking directly at my plan on her screen, telling them my plan covered it and they had never sent the claim.

Personally I looked at all my insurance options very carefully, especially the exclusions. One company excluded any and all trans treatments and another excluded "injectable drugs". Also make sure to read the individual plan exclusions since they vary and can vary by where you live. The companies seem to be finding ways to exclude our treatments even though they aren't supposed to. Always read your plan exclusions very carefully because many of them exclude brand name drugs and even compounds which I found disgusting and despicable since many people need brand name or compound drugs due to sensitivities and allergies. So really nothing has changed much from how it was before. We're still forced to pay out of pocket for what we need in many cases.

Ok, this isn't a quick solution but there's a couple things you can do. Find out who the insurance commissioner is for your state. Every state has one. See what support they can offer.

At the same time write a letter to your insurance company. clearly document all the issues. Send it through certified mail and let them know you are also sending a copy to the insurance commissioner. Let them know that for any future problems that occur you will also be contacting the insurance commissioner.

This was very wise advice a friend gave me and made a huge difference. When my state passed parity laws for mental health I began to take advantage of increased coverage. And my insurance company did all sorts of crappy things like yours did. Once I sent that letter things were great. A few years down the road the same sort of issues occurred. I sent them a new letter, reminding them about the old letter and the insurance commissioner and I have been covered.

Quote from: christopher on June 10, 2014, 11:09:00 PM
Ok, this isn't a quick solution but there's a couple things you can do. Find out who the insurance commissioner is for your state. Every state has one. See what support they can offer.

At the same time write a letter to your insurance company. clearly document all the issues. Send it through certified mail and let them know you are also sending a copy to the insurance commissioner. Let them know that for any future problems that occur you will also be contacting the insurance commissioner.

This was very wise advice a friend gave me and made a huge difference. When my state passed parity laws for mental health I began to take advantage of increased coverage. And my insurance company did all sorts of crappy things like yours did. Once I sent that letter things were great. A few years down the road the same sort of issues occurred. I sent them a new letter, reminding them about the old letter and the insurance commissioner and I have been covered.

Agree with this! Document everything that went down and file a dispute. If you're on medicaid, they cannot drop you for any reason without telling you first. In my case it was because I was quickly shifted from a statewide medical service to medicaid and then my hmo kicked in. When they went to bill stuff I was getting all sorts of gruff until I went directly to medicaid with my state and talked to them about it. I hope you can get your insurance taken care of.

Hey guys! Okay so I got an update from my dr. I wasn't dropped from my insurance. They just set my account to "inactive" while screwing around after they denied my prior authorization for Androgel. Which is good. So I went back to the pharmacy to see if i could finally get the injectable T. And still no. So my dr called them once again, they won't cover it because I haven't legally changed my gender yet. Had to wait on some legal matter before I could. So now I started the process of a legal gender change with my state and SS. It's in the works. I went and purchased my androgel for $$$$$ uninsured just to keep me from loosing my mind from lack of t after not being on it for nearly 2 weeks. Now I'm hoping I will get it covered. But I have another concern for injections, besides my fear of needles; when I was in high school I was diagnosed with acute bipolar disorder. I told my dr that I didn't want to do injections because of this as well. He seems to think it would be fine. I don't take any bipolar meds currently and haven't since high school because since I started T it's been in-check with little mood swings occasionally. I am strongly biased against the injections because of this and reading so many testimonials from other guys about peak of anxiety and mania right after the injection and depression, low energy, and irritability closer to the time of the next one. I'm gonna open a new thread just about this, but what do you guys think regarding insurance disputes? I'm going to appeal their denial for androgel but with my medical records stating i'm bipolar and my dr and possibly a mental health dr writing a letter saying injections aren't a good option due to this. I'm leaning toward hope with this but am afraid they will rebut with "take bipolar meds."

Oh, fer fook's sake.

Appeal. Definitely appeal. You are not a woman, you are a trans man. You need your meds whether insurance has you coded as male or female or Martian or Jovian.

As for the bipolar and needles, you are saying that they want to force you to inject even though you have a mental illness that the hormones keep in check, but the insurance provider would deny coverage for the hormones that keep your bipolar in check because you weren't on bipolar meds and didn't know that they would require you to be on bipolar meds to get coverage for the version of the hormones that you needed because you weren't on bipolar meds at the time??!!

Even I can't follow that, and I thought I was pretty smart. Sounds kinda crazy to me.

Quote from: Arch on June 12, 2014, 09:49:35 PM
Oh, fer fook's sake.

Appeal. Definitely appeal. You are not a woman, you are a trans man. You need your meds whether insurance has you coded as male or female or Martian or Jovian.

As for the bipolar and needles, you are saying that they want to force you to inject even though you have a mental illness that the hormones keep in check, but the insurance provider would deny coverage for the hormones that keep your bipolar in check because you weren't on bipolar meds and didn't know that they would require you to be on bipolar meds to get coverage for the version of the hormones that you needed because you weren't on bipolar meds at the time??!!

Even I can't follow that, and I thought I was pretty smart. Sounds kinda crazy to me.

Hey, I apologize for being kind of hard to understand! I can be kind of confusing when explaining things! Well, put simply, insurance covered the androgel for six months suddenly needed approval and denied it. They told my dr the reason for the denial was because I didn't try the generic which is only inject-able form. My dr. gave me a script for the generic and the pharmacy told me they didn't cover that either. My dr. called them to ask why they weren't covering the generic and they said they wouldn't cover it because my account says female and I need to legally change that to get anything covered. So while I wait for my legal gender change to finalize; I am gathering medical records to make a case for the appeal. My case being that I am bipolar and can't handle the mood swings from injections and have been in check with a steady everyday application of gel. I plan on having my primary care dr. (who prescribes me t) write a letter and my old mental health dr. write one as well stating injections aren't a good option due to my bipolar. With these letters and my case for the appeal, I pray they will cover my androgel; my only fear is they will come back with a statement something along the lines of, "Well if this person is bipolar they should be on bipolar meds so take that to handle the bipolar, suck it up and take the injections." Am I making a little more sense? Sorry for being confusing.

What I'm saying is that they are not being reasonable. But insurance companies rarely are.

Hey y'all, update STILL. BATTLING with insurance to cover Androgel. I changed my gender legally and it has been updated with medicaid and united healthcare. Currently awaiting yet another prior authorization that was submitted two days ago. Someone from united has been very kind and helping me a lot. She told my doctor what needed to be said to get brand name approved. So hopefully it will be approved. I'm praying it will be because I'm out of the bottle I paid for myself. I'm just so angry that this situation has been going on for over a month now. When the pharmacy tries to submit it, it says "REJECTED PRIOR AUTH NEEDED TRY GENERICS FIRST". The lady whose been working with me said it is because they have a state mandate to pay for generics first. She said there's been many people who never had generics of meds so it is possible. I'm just wondering now.... if it is denied (which i am kinda expecting given they've given me so much trouble) and I try generics (injections) then what are the reasons to "claim" to them that they aren't working? Would gel coverage only be reconsidered if i had allergic reactions to injections? Because obviously they will "work" and give me testosterone. I just do not want to do them at all. Been really happy with the gels. Surgery is two weeks from now and I just want the stress of this matter to go away and be able to get my gel. :/

Quote from: BGking on June 12, 2014, 09:26:28 PM
Hey guys! Okay so I got an update from my dr. I wasn't dropped from my insurance. They just set my account to "inactive" while screwing around after they denied my prior authorization for Androgel. Which is good. So I went back to the pharmacy to see if i could finally get the injectable T. And still no. So my dr called them once again, they won't cover it because I haven't legally changed my gender yet. Had to wait on some legal matter before I could. So now I started the process of a legal gender change with my state and SS. It's in the works. I went and purchased my androgel for $$$$$ uninsured just to keep me from loosing my mind from lack of t after not being on it for nearly 2 weeks. Now I'm hoping I will get it covered. But I have another concern for injections, besides my fear of needles; when I was in high school I was diagnosed with acute bipolar disorder. I told my dr that I didn't want to do injections because of this as well. He seems to think it would be fine. I don't take any bipolar meds currently and haven't since high school because since I started T it's been in-check with little mood swings occasionally. I am strongly biased against the injections because of this and reading so many testimonials from other guys about peak of anxiety and mania right after the injection and depression, low energy, and irritability closer to the time of the next one. I'm gonna open a new thread just about this, but what do you guys think regarding insurance disputes? I'm going to appeal their denial for androgel but with my medical records stating i'm bipolar and my dr and possibly a mental health dr writing a letter saying injections aren't a good option due to this. I'm leaning toward hope with this but am afraid they will rebut with "take bipolar meds."

this happens when you have your injection every 2 weeks. if you do it every week, your moods will be more stable. i just thought i'd point that out. gel seems to be working for you but injections are also cheaper. it just sucks because a lot of things don't cover it unless you are a cis gender male who needs testosterone for a medical condition and being transgender isn't considered one to a lot of people so it doesn't get covered.