I was wondering if you guys knew of anyone who had tried Plume to get their hrt prescriptions. I'm considering the service but I'm a little wary because it seems too good to be true.

Lee says:

Their website’s FAQ says:

Plume is currently only available for people 18 and over, so you can’t be a minor.

You cannot use insurance, Medicaid, or Medicare to pay for Plume. 

The out-of-pocket total cost for Plume is $1,188 (one thousand, one hundred, and eighty eight dollars) per year, plus the cost of the copay for buying the HRT from the pharmacy.

Breaking it down:

I think it really depends on your situation. When I started testosterone, I lived in CT, which isn’t a state that they offer services in.

You have live in one of the following states:

Whether or not Plume is a good option for you depends on a few factors. Do you live in one of the states they cover? Is paying $1,188.00 per year going to be less expensive than the cost of seeing a doctor and getting lab work using your insurance? 

Here’s an example: I had an appointment when I started T, then another at 3 months, at 6 months, and at 1 year on T. Each appointment was covered by my insurance because I saw an in-network provider, and it had a $40 specialist fee copay. So that’s a total of $160 out of pocket for appointments in one year. 

But of course, that’s only the appointments! I also had blood work done each time, which my insurance mostly covered, and I’ll put that at $100 per lab. So that’s a total of $400 out of pocket for labs. 

So in one year, I paid $560 in total, which means Plume would have been more expensive for me.

Let’s note here that I was not even including the price of testosterone, which for both options you’d be either paying out of pocket, paying with a GoodRx coupon, or trying to get insurance to cover it and paying a copay. So let’s say I was on testosterone gel and had a $30/month copay because it was covered by my insurance but more expensive than injections. So let’s put that at $360.

In one year, I’d pay:

Now I had pretty bad insurance. If you have better insurance which charged you only a $20 copay for your appointments, or you only had to pay $50 per lab, or you were on testosterone enanthate injections and only paid $10 for a three month’s supply of testosterone, you’d be saving even more money.

Of course, the reverse is also true- if you have worse insurance than I did, your costs could be higher than the ones you’d be paying with Plume, especially if you were paying for all your lab work out of pocket. That’s where the costs really add up.

The Plume website offered these suggestions for defraying the cost:

The easier access with Plume also factors in to people’s calculations as well. 

But of course, minors can’t use Plume right now, even if they have parental consent.

Note that you can start HRT as a minor elsewhere, you just have to have permission from your legal guardian to start HRT if you’re under 18 unless you’re an emancipated minor. This post should help with getting the conversation started with your parents about starting HRT.

Some endocrinologists don’t allow someone to start HRT until they’re 16, but this is up to the prescriber’s discretion because there are no laws saying what age is too young to start hormones- some people even start HRT at 13. You do have to have started puberty to get HRT. If you haven’t started puberty yet, you should look into puberty blockers.

If you’re a minor and can’t use Plume, or you’re 18+ and want to explore your other options, here are the two most common methods for accessing HRT:

Option 1: Informed consent

Informed consent. This means that you discuss the effects of transition with a doctor, typically an endocrinologist or urologist (which more common for AMAB people), and confirm that you understand what you’re getting into.

Legally any medical provider who can prescribe medication can prescribe testosterone, but few of them are willing to do so because they don’t have experience with prescribing testosterone and ordering and interpreting the blood work and ensuring you’re healthy, so they aren’t comfortable doing it.

You’ll have to read and sign a document that lists all the changes to expect and potential health risks. (Examples of that document are here). You’ll get some tests done and then you’ll be good to go!

Important to note: You must be 18 years of age or older to consent for yourself. I haven’t heard of any minors getting informed consent with their parents’/guardian’s help, although it may be possible. Also, not all insurances will cover informed consent services because they may require WPATH letters sent to them to approve gender dysphoria treatment/coverage. If you want insurance to cover your HRT, speak to your insurance provider (call the number on the back of your insurance card).

Resources: ICATH has some good US-specific resources for informed consent. @plannedparenthood also provides informed consent services for HRT in some locations.. This Google Maps list here has a lot of informed consent clinics listed as well to check out, although it’s not a full list of all of them.

Option 2: Therapist’s letter

Therapist’s letter. This is the “traditional” method, based on the WPATH Standards of Care. Basically, you talk to a therapist, sometimes for several months. Usually, the therapist is one who knows about gender identity issues, or even specializes in them, but it doesn’t have to be - the main idea is that you’re looking for someone who can keep up with you and isn’t going to tell you that you’re mentally ill because you’re trans, so finding an LGBTQ-friendly therapist is a must. They write a letter that follows the guidelines in the example below, hand it off to insurance and your doctor, and you’re on your way. An example of that letter is here.

How long you have to see your therapist before their letter will work for you depends on a) the therapist, b) the doctor you want to see, and c) your insurance (if you plan on seeking coverage). You’ll have to communicate with all of these people in order to work out their requirements. The timeframe is typically around 3 months, but it can be longer or shorter depending on those factors. Information on getting a trans-friendly therapist is here.

Important to note: Not all insurances will cover HRT with a therapist’s letter, either, although many states are making it illegal to deny transition-related services. Be sure to check with your insurance provider first! Check out our Getting insurance to cover your transition post.

After that:

Finding a doctor can also be hit-or-miss. You can speak to your GP (general practitioner; i.e. the doctor you go to for regular checkups) - sometimes they know what they’re doing, and I’ve definitely heard of GPs prescribing HRT or hormone blockers to their patients.

You can start with contacting your primary care doctor and asking if they can prescribe your T, or if they have any referrals to places that do prescribe HRT. Some people can get their HRT prescribed by pediatrician/general practitioner!

However, most of them will refer you to an endocrinologist (and many insurance plans require referrals before you can skip off to a specialist, too) for the actual hormones. Then you can also check with local Planned Parenthoods to see if they prescribe HRT or if they can refer you to someone who does.

You can also check with your insurance to see if they cover any endocrinologists in the area, then contact those endocrinologists who see If they can prescribe your T, or if they have any referrals to places that do prescribe HRT.

You should also reach out to the trans community IRL- they have to be getting their hormones from someone! If there are any trans support groups in your area, or LGBT organizations, ask them if they have any providers they can point you to.

And finally, it can also be helpful to simply do some googling! I (mod Lee) found my endo by google. It can take some legwork to find a trans-competent doctor who will prescribe HRT, but you just gotta keep trying!

I started HRT at Planned Parenthood with a nurse, then I switched to an endocrinologist associated with a local hospital, then I moved states and got my T from a nurse at Callen-Lorde. While endocrinologists often specialize in HRT because hormones are part of the endocrine system, you can get HRT prescribed by many nurses, and by pretty much all doctors including psychiatrists and urologists.

Some doctors won’t let you do HRT. It’s okay if you shop around. Look around online; call their office first to make sure they work with trans patients. Remember, if a doctor refuses you healthcare, you have a right to refuse them your business!

Once you get to a doctor, you’ll get a preliminary blood test and a general health screening to check for contraindications (any medical conditions that might make it difficult or impossible for you to be on HRT). Nearly every contraindication is possible to work around, though, so don’t worry too much! They’ll likely be looking at your cholesterol levels and heart and liver functions in particular, although this may vary from doctor to doctor and treatment to treatment.

Finally - as long as all medical conditions are sorted out - you’ll be prescribed your hormones. You can choose which delivery method you receive.

For testosterone, the most common forms include injections (which involve needles, but typically only need to be administered once a week or every 10 days), patches (daily, can badly irritate sensitive skin), and creams / gels (daily, have to be careful so that you don’t get it on another person). More info on testosterone is in the Testosterone FAQ.

AMAB folks will need to take both estrogen and an anti-androgen. Typically, estrogen is oral, but can also come in the forms of injections; anti-androgens are nearly always oral. More info on estrogen is in the Estrogen & anti-androgens/testosterone blockers FAQ.

Stick to the instructions they give you in terms of dosage and administration - they give these instructions for good reason! Your doctor should monitor your hormone levels and health status / conditions, and will likely adjust your dosage as time goes by to ensure it is still accurate, so make sure you continue to go in for checkups.

So that was how you’d be looking into starting HRT if you weren’t using Plume.

But if you live in a rural area, and there’s no Planned Parenthood that’ll prescribe testosterone near you, there’s no LGBTQ+ clinic anywhere, your primary care provider refuses to prescribe your testosterone, you’ve called around to other general practitioners in the area and nobody else is willing to do it either, and after a bunch of back and forth phone tag with their office the only endocrinologist in a 500 mile radius eventually says they won’t treat trans people, you can’t find urologist or psychiatrist who feels comfortable doing it, etc, and you find yourself having to first jump though the WPATH hoop and find a therapist willing to write you a letter and then find a way to travel 4 or 5 hours for your HRT appointment and then you have to fight with your insurance to get blood work covered... Plume is going to start looking more appealing even if you do end up having to pay more.

Personally, as someone who is on HRT, and has recently moved to a Plume-covered state, am not tempted to switch to Plume at all. I’m lucky enough to have moved to NY and while it does take me around an hour and a half to two hours on public transport to get to my doctor, I was just approved for NY Medicaid and now I basically pay $0 in total for my appointments, blood work, and my prescription costs are capped at $3 per prescription. So at max I’m paying $36 per year now.

Another alternative to Plume is QMed.

They write “QMed accepts patients of all ages and provides puberty blockers for those yet to enter puberty,” so you can get HRT or puberty blockers from them as a minor, but you do need to have permission from your parent/legal guardian to do so.

They do say that “All states require that patients receiving testosterone need to have at least one in-person appointment prior to starting hormone therapy. When we receive your first appointment request, we will help you determine if and when you will need that required visit,” so it may be an easier for people starting estrogen than people starting testosterone. But I think that’s different now- their most recent update says: “Prior to the spread of COVID-19, an in office visit was required for the initial consultation for testosterone. However, the government has waived this requirement until further notice, so we are only offering video visits until the pandemic is under control to protect our patients, families, and staff.”

They say they accept Aetna, SOME Blue Cross PPO plans, Cigna, Humana, PHCS. But they do not take Medicare, Medicaid, Peachstate, Ambetter, United, or Kaiser. If your insurance is accepted, the cost will be the same as it would be to go to an IRL prescriber.

If they don’t accept your insurance and you self-pay for some of their appointments the first visit will cost $299, and visits after that will cost $149. But you’ll only have to pay when you have an appointment, so there’s no monthly fee. Blood tests will be $99 each time they check hormone levels, which may be needed up to 4 times in the first year, and 1-2 times per year after that.

QMed uses the informed consent model for patients 18 or over, so a therapist visit is not required. But a letter from a mental health professional following WPATH standards is necessary to start hormones if you’re a minor.

Plume is currently only available for people 18 and over, so you can’t be a minor, but QMed does accept minors who have parental permission.

Anyway, back to the Plume thing! I haven’t heard anything bad about them in the posts I’ve read online though. Most people seem pleased but frustrated with the cost. One person wrote “The sign up process was on multiple apps and intake forms were disjointed. While this may be useful for new people who wanted to start HRT, for folks wanting to continue care I found the question about how long have you felt this way, how long have you been living in your gender offensive.”

I don’t personally know anyone who has done it because most of the folks I know don’t constantly have $99 each month to pay out of pocket so they tend to go the traditional route even if it’s harder logistics-wise, but I don’t live in a rural area so going the traditional route is a possibility for us, and it might not be so easy for others.

The one thing I’d remind everyone of is the cost. Losing access to testosterone can be a physical health issue if you’ve had a hysterectomy and oophorectomy and are worried about osteoporosis without having a dominant hormone, and the same if you’re on estrogen and had an orchiectomy, so remember that the $1,188/year cost for Plume doesn’t include your hormones themself! So consider how much the individual testosterone vial/estrogen patch/antiandrogen pills/etc will cost when you go to the pharmacy to pick it up!

Followers, has anyone over 18 used Plume to get their HRT prescription and would you recommend it? Or have you heard anything cautioning against it?