When you first start hormones, your insurance information changes, or route or dose of medications change, your insurance may require prior authorization. Prior authorization is the process of determining whether an insurance company will cover your medication. The process works as follows: PPCWNY sends your prescription to your pharmacy; typically your pharmacy will then contact PPCWNY to let us know if a prior authorization is needed; our PPCWNY team will then initiate and complete a prior authorization submission to your insurance company. A determination of coverage by the insurance company may take 7 business days (or more if a denial is encountered or additional information is requested). If your prescription requires a prior authorization and you have not heard back about a determination a week after the prescription was sent, please contact us via the portal for an update. See below for more information. 

Even with insurance coverage, prescription costs vary. If the out-of-pocket cost for your medication is cost-prohibitive we recommend using GoodRx with your chosen pharmacy to explore options for price reductions using coupons. If the cost remains too high, we encourage you to let us know and we may be able to suggest alternative medication routes that may be more affordable. In general, if paying out of pocket, estradiol pills, spironolactone pills, and testosterone injections are the least expensive regimens; if you are concerned about medication costs, we encourage you to bring this up at your visit when you are making a medication plan.

Testosterone is a controlled substance. Based on current law, clinicians must rewrite testosterone prescriptions every 6 months. While individuals on stable testosterone regimens usually only require clinic visits and labs annually, a clinician is required to electronically resend your prescription for testosterone every 6 months when you are on a stable regimen. 

We will provide prescriptions for needles and syringes with injectable medications. For those who use syringes and needles, please ensure the needle length, gauge, and syringe volume are accurate for you prior to leaving the pharmacy. The pharmacist will be the most helpful person in resolving any issues with this. If you are prescribed two different needle sizes for one syringe, it is important that you are able to attach and detach each of the needles to the syringe. If you are having trouble finding your needles or syringes in stock at a pharmacy, please be aware that syringes and needles can also be purchased over the counter at suppliers including Amazon for syringes and needles, Bulk Syringes, or the non-profit Trans Needle Exchange. Sharps disposal bins can also be purchased at the pharmacy; or, sharps can be disposed of in hard plastic containers (like a laundry detergent container) labeled “Sharps” with a sealed and taped lid. More information regarding disposing of sharps (needles) in New York can be found here. 

When able, our clinicians typically send 3-month prescriptions with or without refills to your pharmacy. It is important to keep track of when your lab draws are due. Depending on your medical situation (the labs you have previously had, and the medications you are on), clinicians may or may not be able to provide refills when labs are overdue. Most people who have been on hormones for a year, and are on a stable regimen, will require annual labs.  

Gel and injection medication prescriptions may be written to reflect a range of dosing (ie: inject 50-100mg into the muscle each week as directed) to ease the process of dose adjustments. If your prescription is written in this way, please use the dose recommended by the clinician and speak with a clinician before making adjustments. 

You can update your pharmacy in our system using your patient portal or at your next appointment. You can call your pharmacy to transfer existing prescriptions to a new pharmacy with the exception of testosterone. Because testosterone is a controlled substance, we will need to resend testosterone prescriptions to your new pharmacy. 

Every plan has its own formulary (catalog of medications) it will cover. The insurance formulary also specifies if a prior authorization will be needed. Not all medications require a prior authorization for approval but some do. We have a team of navigators that can help you if prior authorization is required.

Prior authorizations are only needed when you wish to use insurance to cover a medication, which can lower out of pocket fees, like copays.  

No, you will not need a prior authorization if you are not using insurance coverage to obtain your medication. If you already have a prescription from a medical provider ready for pick up at the pharmacy, you can tell the pharmacist that you don’t want to use insurance (even if the pharmacy has one on file!). Please be aware that some medications may be more expensive when you don’t use insurance, and a drug discount coupon from GoodRx can be used to lower the price.  

If you have recently switched plans, make sure your pharmacy has the correct one on record for you.

If you have more than one insurance plan, your pharmacy will usually try to bill your primary plan first before using a secondary plan. If you have multiple active insurance plans, we ask that you confirm with your pharmacy which plan was billed for your prescription; once you receive this information, please send us a portal message to let us know. This will help us reach out to the correct plan faster and more easily if prior authorization is required!

Tip: If you have a Medicaid plan and another active plan, the Medicaid plan will be your secondary plan most of the time because it’s a payer of last resort, meaning that, if you have another plan that can be used for coverage, it has to be used first.  

You can check with your insurance company ahead of time to see what medications they cover and if those medications require prior authorization. You can also wait until your pharmacy receives your prescription and they will then initiate a prior authorization request with PPCWNY.

PPCWNY recommends calling your pharmacy prior to picking up medication to confirm the status of your prescriptions. By calling, you might find out that your prescriptions have been filled without issue or that there will be a delay due to prior authorization.   

No. Unfortunately, we cannot be certain whether a prior authorization will be needed when we send your prescription. Each insurance plan has its drug formulary (a catalog) of which medications they may or may not cover and insurances have different criteria that must be met for coverage.