Insurance coverage for menopause care is more straightforward than people expect — but with some specific gotchas worth knowing about. Here's what's typically covered under the plans we accept (BCBS, Anthem, CareFirst, Aetna, Cigna, UHC), plus the parts that aren't.
This is general guidance based on how these plans typically operate. Your specific plan can vary, and we always recommend checking with your insurer for the details. But this should give you a workable map.
What's Almost Always Covered
Your annual well-woman visit. Under the ACA, an annual preventive visit is covered with no out-of-pocket cost on most commercial insurance. This includes a Pap smear, pelvic exam, and breast exam at appropriate intervals.
FDA-approved hormone therapy prescriptions. Estradiol patches, gels, oral tablets, and most progesterone formulations are standard prescription medications and are covered under your plan's pharmacy benefits. You'll typically pay a copay, which depends on your plan tier.
Vaginal estrogen (Estrace cream, Vagifem, Premarin cream, the Estring or Femring). Standard prescription drug benefit applies.
Generic versions of hormone therapy — almost always cheaper than brand name. Most patients can use generic estradiol (oral, patch, or topical) and generic micronized progesterone with equivalent results.
Labs related to menopause evaluation — thyroid panels, CBC, lipid panel — are usually covered when ordered for a clinical reason. Coverage may apply to copay or deductible depending on your plan.
Pelvic ultrasound when ordered for a clinical reason like abnormal bleeding. Subject to your plan's imaging benefit.
Telehealth visits with us — covered the same as an in-person visit by all the plans we accept.
What's Sometimes Covered
Bone density scans (DEXA) — covered for most women starting at 65, or earlier if you have specific risk factors. If you're under 65 with no risk factors, your plan may not cover it.
Specialty hormone formulations — pellets, injections, or specific brand-name options may have prior authorization requirements or be excluded depending on your plan.
FSH and estradiol blood tests — not particularly useful diagnostically in perimenopause (they fluctuate too much), and some plans won't cover them. We don't usually order them for perimenopause evaluation anyway.
What's Usually Not Covered
Compounded "bioidentical" hormones from compounding pharmacies. These aren't FDA-approved, and most insurance plans don't cover them. Out-of-pocket cost typically runs $40-150/month depending on the formulation. We mostly prescribe FDA-approved bioidentical hormones, which are covered.
Cosmetic or wellness add-ons. Things like vaginal rejuvenation laser treatments, hormone "optimization" packages from concierge clinics, and similar are not insurance-covered services.
Out-of-network providers. If you see a menopause specialist who's not in your plan's network, your out-of-pocket cost will be much higher. The plans we accept (BCBS, Anthem, CareFirst, Aetna, Cigna, UHC) all consider us in-network.
What If You Have Medicaid, Medicare, or Tricare?
We don't currently accept Medicaid, Medicare, or Tricare. If you have one of these plans:
Medicaid (Maryland, DC, Virginia) — covers menopause-related care at participating providers. Federally Qualified Health Centers (FQHCs), Planned Parenthood, and your local health department are starting points. We have a [separate post about why we don't take Medicaid and where to look](/blog/why-we-dont-take-medicaid).
Medicare — typically covers preventive visits, hormone therapy prescriptions, and labs through Part B and Part D. Most OB-GYN and menopause specialists in the area accept it.
Tricare — covers menopause care at network providers; check the Tricare provider directory for nearby in-network options.
Self-Pay Patients
We do offer self-pay rates for patients without insurance or who prefer not to use it. Contact us for current pricing on consultations, follow-ups, and procedures. We try to keep these reasonable for the type of care being provided.
For prescription medications, GoodRx and Mark Cuban's Cost Plus Drugs (costplusdrugs.com) often have generic estradiol and micronized progesterone for under $15/month. We can send prescriptions to whichever pharmacy works best for you.
Common Coverage Questions
"My plan denied my hormone prescription. What do I do?" Usually a prior authorization issue. We can submit one. If a brand name is denied, we can often switch to a covered generic.
"My deductible is enormous. Will I owe a lot?" Preventive visits are covered before deductible by ACA-compliant plans. Other visits go toward your deductible. If cost is a concern, ask us before the visit and we can help you figure out what to expect.
"Why does my friend's plan cover X but mine doesn't?" Plans within the same insurance company can have wildly different formularies and coverage rules. Generic-versus-brand decisions and prior auths vary plan-to-plan. The frustrating answer is: it really is your specific plan, not the insurance company in general.
How We Help
When you book with us, we'll verify your benefits before your visit and let you know what to expect for cost. If something gets denied or kicked back by your plan, we'll work on it with you — prior auths, appeals, and finding covered alternatives are part of what we do.
Book online, view our full insurance page, or send us a message with questions about coverage.