Does Insurance Cover Menopause Care? Costs, Coverage, and What to Know

If talking (or even reading) about insurance isn’t your idea of a good time, you’re in good company. Our team will be the first to admit that health insurance is a complicated, sometimes grizzly beast…which in turn makes it all the more important to try and understand.

In the wise words of Jen Golladay, Elektra’s VP of Clinical Operations and in-house insurance expert: “No two insurance plans are exactly the same. My best recommendation is to get to know yours, and ask the questions. At the end of the day, you are your own best advocate, and you can’t advocate without knowledge.”

We tapped Jen to learn more about the ins and outs of insurance when it comes to menopause care.

Insurance FAQs: Menopause Edition

Does insurance cover menopause care?

In many cases, yes! At Elektra, we are proud to offer high-quality, menopause-centered midlife care to people of all backgrounds and insurance types, including private and government-sponsored insurance.

What’s the difference between a copay and coinsurance?

Copays are flat fees that patients pay when seeing a healthcare professional or filling a prescription, and you’ll typically pay on the spot. If you’ve ever gone to urgent care and had to pay a fee with the receptionist upon arrival – that’s a copay.

Unlike a copay, coinsurance is the percentage you’re required to pay for medical costs after you’ve met your deductible. You may see this represented on your insurance card as a ratio. For example, a 70/30 plan means that once you’ve hit your deductible, your insurance will cover 70% and you’ll cover the remaining 30%.

Can Elektra provide an estimate for my co-pay?

Every plan is different, and things like co-pays, deductibles, and co-insurance vary. Our clinicians are typically considered to be specialists, so your specialist co-pay will likely apply. If you’d like to know what your exact out-of-pocket responsibility will be, your best bet is to contact your plan and ask what your estimated out-of-pocket cost is for a specialist telehealth appointment.

Does Elektra require a referral?

While Elektra does not require that you receive a referral for care with one of our clinicians, your insurance may. We recommend confirming with your insurance prior to a visit whether a referral is required. If you do find that your insurance requires a referral, we’re happy to work with you to get your PCP all the relevant information.

It can take time for referrals to be completed, so we recommend reaching out to your healthcare provider for a referral at least a week in advance of your appointment at Elektra. If you do not have a referral in time for the visit, we will be unable to bill your insurance and you will be billed for the full out-of-pocket cost.

Does a visit with Elektra include medications?

At Elektra, the patient experience actually looks quite similar to what you’d experience in person – just more convenient! During an appointment with a clinician, you’ll work together to build a treatment plan based on your unique needs and overall health history, which may mean prescription drugs or supplements. In some cases, a patient and clinician may decide that lifestyle changes alone are the best place to start! If your treatment plan includes medication, it will be a separate cost.

Will insurance cover my prescriptions?

Coverage for medications varies between health insurance plans, which in the U.S. includes employer-sponsored plans, individual plans, and state-sponsored plans such as Medicare and Medicaid.

Many insurance providers cover menopausal hormone therapy (previously referred to as hormone replacement therapy or HRT) for the treatment of menopause symptoms like hot flashes/night sweats. It’s worth noting that coverage also depends on the type of hormone therapy; FDA-approved hormone treatments tend to receive better coverage.

At Elektra, we prescribe both hormonal and non-hormonal FDA-approved medications. We’ll also work with your pharmacy and insurance to get your medications covered when possible.

What happens if my insurance requires a prior authorization?

A prior authorization is an approval your insurance company may require to determine if they will cover a medication. This helps confirm that the treatment is medically necessary. If your insurance requires a prior authorization, our clinical support team will work with your Elektra clinician to submit a request for coverage. We’ll provide all necessary documentation and follow-up until a decision is made.

The bottom line:

Insurance is complex, but having a basic understanding of how it works is a tremendously helpful tool to have in your back pocket, and can make navigating the healthcare system easier.

Learn more about clinical care at Elektra and find out if you’re covered >>

READ MORE:

• Here’s What to Look For in a Menopause Specialist
• Is Vaginal Estrogen Safe? What The Science Says.
• Progesterone vs Progestin: What’s The Difference?