So, without context, this question sounds really strange. I’ve been on DIY HRT since the 15th of January, 2025 (started on estradiol valerate pills with cyproterone acetate). I switched to estradiol cypionate injections on the 6th of May, 2025, and have been using it since then. I’ve dialed in a stable EC dose for monotherapy that has given me adequate testosterone suppression (this month’s labs show 15ng/dL). I’ve been getting regular bloodwork, and have an exact timeline of my dosage adjustments since I started HRT. I’m also in the US, since that’s likely relevant.
I now want to start progesterone, and I want to just get a prescription for 2 reasons: price, and a letter of support for surgery showing I’ve been on HRT 2+ years by the time I get surgery (for insurance coverage). But if I’m to get a progesterone prescription, I’d also be getting an estradiol prescription. The problem is that I’m stable on EC, but even if my insurance were to cover it (under the brand name Depo-Estradiol, it’s a Tier 3 drug since it doesn’t have a generic), it would be $100 for a 90 day supply (3 vials). Uninsured, it’s $250/vial, and I find it likely it won’t be covered, as EV is a Tier 1 covered drug (they’d want me to take that instead because it costs the insurance less for a generic).
I have concerns with starting EV, because my dose would have to be dialed in again, and my estradiol levels would be far, far more erratic. EC has a much longer half-life than EV, so it keeps hormone levels much more stable. With EV at an “equivalent dose” (keeping the average over the week the same as the EC I’m currently on), I’d have much higher peaks, and much lower troughs, and I’m concerned that it will worsen my mood swings (I’m bipolar, but have been doing better with medication). There’s also the downside that Depo-Estradiol is only available in 5mg/mL concentration, so I’d be injecting 8x more volume than my 40mg/mL DIY vial.
So, if I were to get a prescription, here are my options (in no particular order):
- Switch to EV and be forced to dial in the correct dosage to adequately suppress testosterone while minimizing supraphysiological serum levels of estradiol
- Get an EC prescription and risk no coverage (and pay as much for 3 months as I do for 2 years DIY if it is covered)
- Get an EV prescription and fill the drug, but keep taking my EC
- Get an EV prescription and don’t fill it while continuing EC
- Get an EC prescription and don’t fill it while continuing DIY (because I don’t have that kind of money)
I believe the insurance will not be checking my prescription history, since I could choose not to use insurance at all for it; they just ask for a letter from my prescribing provider. I’m also aware that in the US, providers can check if you’ve filled a prescription (and sometimes even be notified when you fill/decline to fill a prescription). I’m apprehensive to discuss this with the provider I’ll be seeing, as they may become suspicious that I’m not following my treatment regimine, and thus may deny me a letter when the time comes.
So I’m kind of at a loss for what to do here. The option I feel most comfortable with is filling EV, but continuing EC, as EV is really cheap (<$10/month). That also leaves a trail of prescription history. But my labs might show unexpected serum estradiol levels, so my dosage may be adjusted, and then I may get questions about why my serum estradiol levels didn’t change when the prescribed dosage changed. I also feel like throwing out good vials of EV is a waste. So my next preferred option would be to get prescribed EC, and not fill it because it’s so expensive. That way, my bloodwork lines up, but again, prescription history wouldn’t match up.
I just feel a little overwhelmed.
Ask your insurance what their requirements are for surgery authorization, or ask you surgeon as they likely have experience. Most of the time you need a letter of support from your HRT prescriber as well as the 1-3 mental heath letters, and possibly others specialists letters depending on which surgery you’re getting. I highly doubt they’ll use prescription history as a reason to deny coverage. But also ask your doctor if they’d still be willing to write the letter with the DIY HRT. It’s still “hormone therapy” and if they’ve been monitoring your blood levels, that should be enough to satisfy the out if date WPATH requirements mist insurance still follows.
However, all that said, some insurance companies will be following exceptionally old WPATH versions just as a reason to deny coverage. So, ask them and/or the surgeon with experience with that insurance exactly what’s typically required.
My insurance uses WPATH SoC 8, so it’s one letter of support from a qualified mental health provider (already have that), and one letter from my “HRT prescribing provider” certifying that I have been under their care and have completed 2+ years of HRT successfully under their guidance (or a letter stating why I need an exemption from the HRT requirement if I were to have some medical reason I couldn’t get it).
Oh, well SoC 8 actually only recommends 6 months and it also recognizes non-binary people may require genital surgery, but may not want HRT at all. My insurance says they follow SoC8 but in reality still follows SoC7. So I was required to have one year of HRT with no exceptions for me being agender, and 2 mental health letters plus the HRT prescriber letter.
I’ve also seen some still following SoC 6 which I can’t find a copy of right now but I think that’s the one that required 2+ years HRT, plus some number of years “living as a woman” and also required that mental health letters be from one provider you have extended history with and one you had no history with. The friend I had who needed to comply with that was unable due to mental heath provider shortages and having been on wait lists for providers for over a year, so no chance to establish enough care with one.
If they truly follow SoC-8, which I haven’t seen any actually do that in practice, then you should be totally fine. But again, they dont have to follow the guidelines by law or anything, insurance isn’t a healthcare system that follows medical guidelines that aren’t legally mandated, it’s a risk-based business that provides care to reduce the likelihood of future, more expensive claims. And these days if you get your insurance from an “employer funded plan” and that employer’s headquarters is not in your state, they dont even have to follow state legislation. O have that issue since my state has laws stating trans people have to be provided any care that would be given to a cis person of that gender, but my insurance denied my HRT repeatedly saying that law didn’t apply despite me living and working here and my employer actually being the sister company of my the insurance company who processes the claims (and I was originally hired by before the company created a new company headquartered in a conservative state and transfered most of us to). Every case is different depending on plan details, cost cutting policies currently in place, or just randomly having bad luck and getting a processor or medical who is anti-trans. So verify specifics with them and get them in writing or better yet talk with a surgeon with experience working with them to clarify.
Okay yeah, my insurance claims to follow SoC 8, but I’m looking at the document that outlines gender affirming care coverage, and it depends on the surgery. For anything except genital surgery (FFS, top surgery, HRT, hair removal (yes my insurance covers laser and electrolysis), etc), it’s “one required referral from individual’s qualified mental health professional competent in the assessment and treatment of gender dysphoria”, and for any form of genital surgery, it requires referrals from 2 independent qualified mental health professionals. Note that there is not a letter from an HRT provider required, but the surgeons I will be seeing for FFS and GRS both require a letter from an HRT prescribing provider documenting continual supervised hormone therapy for 1 or 2 years respectively. I have a therapist (LICSW) and a psychiatrist (PNP), so I have that sorted already. I’ve also confirmed with my insurance that my therapist is “qualified”, as they’ve already accepted the letter I got from her (the one I’m using for HRT). And I already know my plan benefits, so I know everything will be covered (and how to find what documentation I need).
But that was never really the question, my post was entirely about what I should do when I see the provider I’m going to get HRT from, as I’ve already established a stable state. I have all the documents I need detailing how to get coverage, surgery is just so far out that I haven’t looked over the specific requirements in awhile.
Yeah, sorry, got on a tangent since it has brought me and tons of people I know a lot of anxiety. And I work for an insurance company and it frustrates me to no end. 😁
Definitely ask the surgeons’ offices since they have the experience and will be the ones having to negotiate with the insurance. If you don’t have a surgeon picked out and on their wait-list to ask for one of the surgeries, then I’d definitely ask your general practice provider or whoever is monitoring your hormones if they are willing to write the letter anyway. You’ll have to wait to actually get it written since they’re only good for a year, but knowing your doctor will do it is always good.
I am surprised any surgeons are requiring 2+ years of HRT which is SoC 6 era gate-keeping requirements. Insurance I understand because they dont want to pay claims, but seems like surgeons should be more up to date (unless they’re just following what the insurance has required based on past experience).
You may also want to inquire to your insurance if they have a program to advocate for patients and their providers with complex cases. Mine has it and I don’t know what I would have done without her help. Frustrating that the company has to hire someone to advocate against themselves, but that’s modern insurance…lol
