Insurance Coverage for Women's Testosterone: Navigating Barriers and Costs

The Coverage Paradox: Why Insurance Treats Women's Testosterone Differently

The coding system reveals the problem before claims reach adjudication. Testosterone products carry FDA approval for male hypogonadism—established diagnostic pathways with minimal coverage friction. Women seeking the same hormone face a different reality: no testosterone formulation holds FDA approval for women's health indications in the United States, despite decades of clinical use and substantial research supporting efficacy.

This approval gap creates immediate coverage complications. Claims without FDA-approved indications trigger algorithmic flags for scrutiny, prior authorization requirements, or outright denial. The disconnect reflects regulatory lag that hasn't kept pace with clinical practice. Physicians write thousands of testosterone prescriptions for women annually, addressing symptoms from hypoactive sexual desire disorder (HSDD) to menopausal fatigue and cognitive changes, yet every prescription exists as off-label use.

Testosterone cream for women—frequently prescribed for dosing precision and ease of titration—faces particularly steep coverage barriers, especially when compounded to achieve the lower doses women require. Typical female dosing ranges from 0.5-2 mg daily, approximately one-tenth of standard male protocols. This specification rarely aligns with commercially available concentrations designed for men.

Testosterone pellets encounter similar obstacles. These subcutaneous implants require in-office insertion procedures and exist almost exclusively as compounded preparations, triggering multiple coverage exclusions simultaneously.

The result: coverage becomes less about medical necessity and more about coding strategy, formulary restrictions, and willingness to navigate denials. Coverage barriers originate from regulatory architecture, not clinical insufficiency.

What Most Insurance Plans Cover (and the Fine Print You Need to Know)

Insurance coverage for women's testosterone operates in shades of gray, with approval contingent on diagnosis codes, formulary specifics, and administrative persistence.

Coverage under approved male indications remains exceptionally rare for women. Unless a female patient carries a diagnosis of hypopituitarism or conditions causing profound androgen deficiency, this pathway closes immediately.

Off-label coverage with supporting diagnosis codes offers the most realistic avenue, though success rates remain modest. Insurers may consider claims paired with codes such as N94.89 (other specified conditions associated with female genital organs and menstrual cycle) or N95.1 (menopausal and female climacteric states). Prior authorization becomes mandatory, requiring detailed clinical documentation: baseline hormone panels, symptom inventories, previous treatment failures, and medical necessity rationale.

Studies examining off-label drug coverage suggest approval rates between 30-50% on initial submission, rising to 60-70% after appeal according to insurance industry analyses. The process consumes weeks to months with no guarantee of success.

Formulary restrictions add complexity. Plans maintain strict formularies that may exclude specific testosterone formulations entirely. Injectable testosterone cypionate might appear on covered drug lists while testosterone gels or patches don't. More significantly, compounded formulations typically receive blanket exclusion regardless of medical rationale—a coverage gap affecting most women since commercially available concentrations often exceed appropriate female dosing ranges.

Even with approval, testosterone pellets face steeper obstacles than topical options. Pellets require in-office insertion procedures (coded as minor surgery), carry higher per-treatment costs, and almost exclusively exist as compounded preparations. Insurers frequently deny pellet coverage based on "experimental" designations or insufficient long-term safety data specific to women.

The pattern emerges clearly: insurance companies structure coverage policies around FDA approvals, making off-label women's testosterone prescriptions administratively burdensome by design. Not everyone qualifies for treatment, and eligibility determination requires licensed providers to conduct comprehensive medical evaluation including symptom assessment, baseline hormone testing, and contraindication screening.

The Compounded Medication Coverage Gap

The exclusion of compounded medications from insurance coverage creates perhaps the most significant barrier for women seeking testosterone therapy. Most insurance policies contain explicit language stating they do not cover compounded preparations except in rare circumstances—typically when no FDA-approved alternative exists and prior authorization receives approval and the compound is prepared by specific network pharmacies.

For women's testosterone, these exceptions rarely apply. The insurance logic follows a clear path: Why cover a compounded formulation when FDA-approved testosterone products exist? The fact that those products are approved for men, dosed for men's physiology, and clinically inappropriate for women's needs doesn't factor into the algorithm.

Physicians prescribe compounded testosterone cream for women precisely because of dosing limitations. A typical prescription specifies 0.5-2 mg testosterone daily, allowing precise titration based on symptom response and laboratory monitoring. Commercially available testosterone gels approved for men deliver 50-100 mg per application—doses that far exceed safe female ranges and risk significant androgenic side effects. Asking a woman to apply a fraction of a male gel packet introduces measurement error and inconsistent absorption.

Compounding pharmacies address this gap by preparing creams, gels, or troches at concentrations appropriate for female physiology. Yet insurance companies point to FDA policy: compounded medications are not reviewed by the FDA for safety or efficacy. Without regulatory approval, coverage remains unavailable.

Representative policy language from major commercial insurers states: "Compounded medications are excluded from coverage when an FDA-approved alternative is available to treat the same condition." The circular logic persists—FDA-approved alternatives treat male hypogonadism, not the off-label indications physicians address in women, yet insurers categorize them as alternatives nonetheless.

This coverage gap forces a binary choice: forgo treatment or pay out of pocket. The compounding exclusion isn't a loophole—it's explicit policy that disproportionately affects women.

Out-of-Pocket Cost Landscape: What to Expect When Insurance Won't Cover

Without insurance coverage, costs vary by formulation, prescribing provider, geographic market, and compounding pharmacy. General ranges provide planning guidance.

Compounded testosterone cream for women typically costs $100-300 per month, depending on concentration and pharmacy. A 30-gram tube of 1% testosterone cream runs $120-180, while customized concentrations or larger quantities push toward the upper range. Pharmacy selection matters—some compounding facilities charge premium prices for additional quality certifications or faster shipping, while others offer economical options.

Testosterone pellets introduce a different cost structure: $300-800 per insertion procedure, required 3-4 times annually. Total annual expenditure often reaches $1,200-3,200 before factoring in the provider's procedure fee (sometimes included, sometimes billed separately at $100-300 per insertion). The upfront cost concentrates into specific quarters, which some patients prefer for budgeting predictability, while others find the lump-sum burden prohibitive.

Monitoring laboratories represent frequently overlooked expenses. Baseline testing before treatment initiation typically includes total and free testosterone, sex hormone-binding globulin (SHBG), estradiol, complete blood count, and liver function tests—a panel costing $150-400 without insurance negotiation. Follow-up testosterone testing at 6-12 week intervals during the first six months adds recurring costs, though frequency typically decreases once dosing stabilizes.

Provider consultations vary dramatically by model. Traditional endocrinology or gynecology practices may charge $150-300 for initial consultations and $75-150 for follow-ups. Geography drives significant variation—metropolitan markets trend 30-50% higher than suburban or rural areas.

Telehealth platforms shift this equation. The Project Rx and similar concierge models often bundle consultation, prescription management, and ongoing monitoring into transparent monthly fees, eliminating surprise billing and reducing total cost through operational efficiency. Patients know costs upfront—a contrast to insurance-based care where deductibles, co-pays, and out-of-network charges obscure total expenditure until bills arrive.

Cost comparison between traditional in-person specialty care and telehealth grows more favorable for the latter as treatment continues. A patient paying cash for quarterly endocrinology visits, separate lab draws, and retail pharmacy compounding might spend $3,000-5,000 annually. Telehealth models with integrated lab coordination and direct pharmacy relationships often reduce that total by 30-40%.

Strategic Approaches to Maximize Reimbursement and Reduce Costs

Even when insurance won't cover testosterone therapy directly, strategic approaches can reduce net out-of-pocket costs:

Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) accept testosterone therapy as a qualified medical expense when prescribed by a licensed provider. Using pre-tax dollars effectively discounts total cost by your marginal tax rate—a 25-35% reduction for many households. The same applies to monitoring labs and provider consultations. Maintain itemized receipts and prescription documentation to support reimbursement if your account administrator requests verification.

Out-of-network reimbursement submission offers another avenue when insurance won't cover treatment in-network. Request an itemized superbill from your prescribing provider detailing CPT codes for consultation (99203-99205 for new patient office visits, 99213-99215 for established patient visits), diagnosis codes, and services rendered. Submit this directly to your insurance company for out-of-network reimbursement. While claims for medication itself may still face denial, consultation and lab work sometimes qualify for partial reimbursement under out-of-network benefits. Success rates vary—expect 20-40% reimbursement in favorable scenarios, nothing in others—but the effort costs only time.

Medical necessity letters from prescribing physicians strengthen prior authorization requests and appeals. Effective letters include specific elements: baseline hormone values demonstrating deficiency, documented symptom burden using validated questionnaires when available (Female Sexual Function Index scores, for example), previous treatment attempts and outcomes, peer-reviewed literature supporting off-label use, and explicit statements that no FDA-approved alternative adequately addresses the patient's specific condition. Professional medical associations including the North American Menopause Society (NAMS) have published positions on testosterone therapy for menopausal women that lend authority to appeals.

Appeal denials systematically. Initial insurance denials shouldn't end the conversation. First-level appeals (often a form with additional documentation) succeed in 30-50% of cases according to insurance industry analyses. Second-level appeals involving external medical review push success rates higher, though timelines extend to 60-90 days. Include clinical guidelines from professional organizations to support medical necessity arguments.

Set realistic expectations. These strategies improve odds but guarantee nothing. The insurance system wasn't designed with off-label women's hormone therapy in mind, and workarounds remain exactly that—partial solutions to structural gaps.

What Licensed Providers Can (and Cannot) Prescribe

Regulatory classification shapes what's possible. Testosterone is a Schedule III controlled substance under the Controlled Substances Act, requiring specific prescribing protocols, DEA registration for prescribers, and documented medical justification. This classification prevents diversion and misuse while ensuring legitimate prescriptions carry rigorous oversight.

Not everyone qualifies for testosterone therapy. Eligibility determination requires licensed providers to conduct comprehensive medical evaluation including detailed symptom assessment, baseline hormone testing, and contraindication screening. Laboratory testing typically measures total testosterone (females generally show ranges of 15-70 ng/dL compared to 300-1,000 ng/dL in males), free testosterone, SHBG, estradiol, and thyroid function. Some providers also assess DHEA-S and other androgens to establish a complete hormonal picture.

Contraindications exclude certain candidates: active or recent hormone-sensitive cancers (breast, uterine), pregnancy or breastfeeding, severe liver disease, untreated cardiovascular disease, and erythrocytosis. The evaluation protects patient safety and ensures appropriateness—it's not a formality.

Ongoing monitoring requirements persist throughout treatment. Baseline and follow-up testosterone testing typically occur at 6-12 week intervals initially, then quarterly once dosing stabilizes. Lipid panels, hematocrit, and liver function tests follow similar schedules. This monitoring addresses both efficacy (symptom improvement) and safety (excessive androgen levels, cardiovascular risk changes).

Compounded formulations serve as alternatives when clinically appropriate, not as inherently superior options to FDA-approved products. The distinction matters—compounding fills genuine gaps for patients who need customized dosing, but it doesn't carry the regulatory oversight of branded medications. Compounded medications are not reviewed by the FDA for safety or efficacy, and providers must discuss this difference openly during informed consent.

Transfer risk represents a specific safety concern with topical testosterone preparations. Skin-to-skin contact can transfer testosterone to partners, children, or other household members, potentially causing virilization symptoms in women and children (premature puberty, behavioral changes, inappropriate genital development). Licensed providers should discuss application site precautions: applying to areas covered by clothing, washing hands thoroughly post-application, and avoiding contact until medication has fully absorbed.

Prescription decisions are made solely by licensed medical professionals after individual assessment. Treatment isn't a consumer choice—it's a medical decision requiring oversight, monitoring, and adjustment based on biochemical and clinical response. Treatment outcomes vary by individual. Realistic expectations about symptom improvement timelines (typically 6-12 weeks for initial effects, 3-6 months for fuller benefits) and the existence of potential side effects (acne, increased hair growth, voice changes at excessive doses) form part of informed consent.

The Telehealth Advantage: Transparent Pricing in an Opaque System

Traditional healthcare's opacity around costs—unknowable final bills until after treatment—creates anxiety that compounds clinical challenges. Concierge telehealth models invert this dynamic by establishing transparent, all-inclusive pricing before the first consultation.

Direct-pay telehealth platforms eliminate insurance gatekeeping entirely. No prior authorization delays stretching into months. No claim denials requiring appeals. No formulary restrictions determining which formulation patients can access. Instead: predictable monthly costs, physician-guided protocols, and medication delivered directly without pharmacy intermediation.

The Project Rx exemplifies this model—precision medicine protocols for hormonal health built on transparent pricing and accessibility. Patients know total costs upfront: consultation fees, medication expenses, lab coordination, and follow-up care bundled into clear pricing structures. The model works because it bypasses insurance complexity entirely, allowing providers to focus on clinical appropriateness rather than billing codes.

This approach offers specific advantages for women seeking testosterone therapy. Providers can prescribe the clinically optimal formulation—whether compounded testosterone cream for precise dosing or testosterone pellets for extended-release convenience—without considering insurance formulary restrictions. Dosing adjustments happen based on symptom response and laboratory values, not coverage policies. Follow-up consultations occur when clinically indicated, not when dictated by billing necessities.

The trade-off deserves acknowledgment: upfront costs versus potential long-term insurance coverage. Patients with comprehensive insurance who successfully navigate prior authorization may ultimately pay less out-of-pocket once deductibles and out-of-pocket maximums are met. But that calculus assumes approval—an outcome far from guaranteed—and tolerates the administrative burden and time delay inherent in the insurance pathway.

For many women, particularly those with high-deductible plans or previous denial experiences, direct-pay telehealth delivers better value. Cost certainty alone reduces stress in complex healthcare decisions. Additionally, telehealth models aggregate enough patients to negotiate favorable compounding pharmacy rates, passing savings to individuals who would otherwise pay retail compounding prices.

Treatment outcomes vary by individual, and no pricing model changes that fundamental truth. But transparent costs allow patients to make informed financial decisions alongside clinical ones—a dignity often absent from insurance-based care.

Telehealth protocols don't replace in-person medical care when medically necessary. Certain clinical scenarios—acute complications, complex comorbidities, surgical interventions—require physical examination and local medical relationships. Responsible telehealth platforms recognize these limits and direct patients toward appropriate in-person care when indicated.

Questions to Ask Before Starting Treatment

Informed decisions require specific information. Before beginning testosterone therapy, consider these questions:

What formulation and dosing does your provider recommend and why? The choice between cream, gel, pellets, or other delivery methods should reflect your lifestyle, symptom pattern, and absorption characteristics. Understanding clinical rationale helps assess whether recommendations align with your needs or whether convenience and cost considerations might be overriding optimal clinical choice.

What are total monthly costs including labs and follow-ups? Break down complete expenses: medication, monitoring laboratories, provider consultations, and any additional fees. Ask about cost variations if dosing adjustments become necessary. Clarify what's included in quoted prices and what might incur additional charges.

Does the provider offer itemized receipts for insurance submission? Even when direct coverage isn't available, proper documentation enables HSA/FSA reimbursement and out-of-network claims. Providers should generate superbills with appropriate CPT and ICD-10 codes without additional charges or administrative friction.

What monitoring schedule is required? Understand laboratory testing frequency, who coordinates blood draws (in-office, local lab, mobile phlebotomy), and how results are communicated. Monitoring compliance directly impacts both safety and treatment effectiveness.

What are realistic expectations for symptom improvement timelines? Providers should discuss typical response patterns while emphasizing that outcomes vary by individual. Improvement in sexual function, energy, mood symptoms, and other concerns typically emerges gradually over weeks to months, not days. Be wary of providers promising specific results or guaranteed timelines—such claims violate appropriate medical communication standards.

Additionally, ask about potential side effects. While appropriately dosed testosterone therapy in women generally maintains favorable safety profiles, side effects can occur: acne, increased facial or body hair growth, scalp hair changes, voice deepening (typically only at excessive doses), and mood alterations. Providers should discuss these possibilities candidly and explain monitoring strategies to catch concerning changes early.

Finally, clarify who makes prescription decisions and on what basis. Prescription decisions are made solely by licensed medical professionals based on individual medical evaluation. Treatment shouldn't proceed without documented hormone deficiency, clear symptom burden affecting quality of life, and absence of contraindications.

Moving Forward: Making an Informed Coverage Decision

The insurance landscape for women's testosterone therapy remains frustratingly limited—a consequence of regulatory lag, FDA approval gaps, and formulary structures built around male hypogonadism treatment. Coverage barriers stem not from clinical insufficiency but from administrative architecture that hasn't adapted to prescribing realities.

This knowledge empowers better navigation. Off-label status creates immediate coverage obstacles, with most insurance requiring prior authorization that succeeds inconsistently at best. Compounded formulations including testosterone cream for women face explicit exclusion from most insurance policies despite representing the most clinically appropriate option for many women given dosing requirements. Testosterone pellets encounter even steeper barriers due to compounding status and procedural insertion requirements. Out-of-pocket costs vary widely—$1,200-$3,000 annually or more depending on formulation, provider model, and monitoring frequency.

Transparent direct-pay models offer an alternative path, trading insurance reimbursement potential for cost certainty, faster access, and reduced administrative burden. For women with high-deductible plans, previous denials, or frustration with insurance complexity, this model often delivers superior value and experience.

The decision ultimately rests on individual circumstances: insurance coverage specifics, financial considerations, symptom severity, and tolerance for administrative navigation. Consultation with licensed providers who can assess individual eligibility and medical appropriateness remains the essential first step. Not everyone qualifies, and determining candidacy requires proper evaluation—hormone testing, medical history review, and contraindication assessment.

The broader system may lag behind clinical needs, but individual options exist. Understanding the coverage paradox, strategic reimbursement approaches, and alternative care models transforms an opaque system into navigable terrain. Treatment decisions belong to patients and their physicians, not insurance algorithms—though the pathway to that decision may require persistence, documentation, and willingness to invest in health outside traditional coverage structures.

For women experiencing symptoms consistent with androgen deficiency—diminished libido, persistent fatigue, mood dysregulation, reduced muscle strength—the lack of straightforward insurance coverage shouldn't close the conversation. It should inform it, clarifying what's possible, what's probable, and what requires strategic effort. Women's hormonal health deserves attention and access, even when insurance infrastructure hasn't yet caught up to that principle.

FAQ

Is testosterone therapy for women covered by insurance?

Coverage remains inconsistent and generally limited. Most insurance plans don't automatically cover testosterone for women because no formulation carries FDA approval for female indications in the United States. Some plans may cover testosterone prescribed off-label with supporting diagnosis codes (such as those for hypoactive sexual desire disorder or menopausal symptoms) after prior authorization, but approval rates remain modest—typically 30-50% on initial submission according to insurance industry analyses. Coverage is more likely for FDA-approved testosterone products prescribed off-label than for compounded formulations, though even then, significant barriers exist. Not everyone qualifies for treatment, and eligibility determination requires comprehensive medical evaluation by licensed providers.

Why don't insurance companies cover compounded testosterone cream for women?

Insurance policies typically exclude compounded medications unless no FDA-approved alternative exists for the condition being treated. Since testosterone products are FDA-approved (for men), insurers categorize them as "available alternatives" regardless of whether they're clinically appropriate for women's dosing needs. Additionally, compounded medications are not reviewed by the FDA for safety or efficacy, which insurers cite as justification for exclusion. The policy logic doesn't account for the dosing mismatch—women typically require one-tenth the testosterone dose approved for men, necessitating compounding for precision and safety.

How much does testosterone cream for women cost without insurance?

Compounded testosterone cream typically costs $100-300 per month depending on concentration, quantity, and compounding pharmacy. A standard 30-gram tube at 1% concentration generally runs $120-180. Additional costs include baseline and monitoring laboratory testing ($150-400 per panel without insurance negotiation) and provider consultations ($150-300 initial, $75-150 for follow-ups in traditional practices). Total annual expenditure often reaches $2,000-4,000 when including all components of care, though telehealth models with bundled pricing may reduce this total. Treatment outcomes vary by individual.

Can I use my HSA or FSA to pay for women's testosterone therapy?

Yes. Testosterone therapy prescribed by a licensed medical provider qualifies as an eligible medical expense for both Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA). This includes the medication itself, monitoring laboratory tests, and provider consultation fees. Using pre-tax dollars effectively discounts total cost by your marginal tax rate—typically 25-35% for most households. Maintain itemized receipts and prescription documentation in case your account administrator requests verification during reimbursement processing.

What's the difference between testosterone cream and testosterone pellets for insurance coverage?

Both formulations face coverage challenges, but testosterone pellets encounter steeper obstacles. Pellets almost exclusively exist as compounded preparations, triggering automatic exclusion under most insurance policies that don't cover compounded medications. Additionally, pellet insertion requires an in-office procedure (coded separately as minor surgery), adding another coverage hurdle. Insurers sometimes deny pellet coverage based on "experimental" designations or lack of long-term safety data specific to women. Testosterone cream, particularly if using an FDA-approved gel prescribed off-label, has marginally better coverage prospects—though still requires prior authorization and faces frequent denials when compounded.

Do I need prior authorization for testosterone therapy as a woman?

Almost certainly, yes. Insurance plans treating testosterone as a covered benefit for off-label women's indications typically require prior authorization before approving claims. The process demands detailed clinical documentation: baseline hormone laboratory results demonstrating deficiency, symptom inventories, diagnosis codes supporting medical necessity (such as ICD-10 N94.89 for conditions associated with female genital organs or N95.1 for menopausal states), and often documentation of previous treatment attempts. The prior authorization review process can take 1-4 weeks, with approvals granted inconsistently. Many women find the administrative burden and uncertain outcome frustrating enough to pursue direct-pay alternatives.

Are there any FDA-approved testosterone products for women?

No testosterone formulation currently carries FDA approval for women's health indications in the United States. All testosterone prescriptions for women—whether for hypoactive sexual desire disorder, menopausal symptoms, or other concerns—constitute off-label use. This regulatory gap creates the foundation for insurance coverage barriers. Some countries, including Australia and parts of Europe, have approved testosterone formulations specifically for postmenopausal women with low sexual desire, but these products aren't available in the U.S. market. The lack of FDA approval doesn't reflect clinical inappropriateness—research supports testosterone therapy's efficacy and safety in appropriately selected women—but rather regulatory and pharmaceutical market dynamics.

How can I get my insurance to cover testosterone replacement therapy?

Maximize approval chances by ensuring complete documentation: (1) Obtain baseline hormone testing demonstrating low testosterone levels relative to female reference ranges. (2) Document symptom burden using validated questionnaires when possible. (3) Have your provider use specific ICD-10 diagnosis codes that align with your symptoms (N94.89 for sexual dysfunction, N95.1 for menopausal symptoms). (4) Request that your provider submit detailed prior authorization including medical necessity rationale and supporting clinical literature. (5) If initially denied, appeal systematically with additional documentation—first-level appeals succeed in 30-50% of cases according to insurance industry analyses. (6) Consider requesting FDA-approved testosterone gel prescribed off-label rather than compounded formulations, as this marginally improves coverage odds. Even with optimal strategy, approval remains uncertain, and not everyone qualifies for treatment.

What should I include in a letter of medical necessity for testosterone therapy?

An effective medical necessity letter contains specific elements: Patient history and symptom documentation with validated assessment tools when available (Female Sexual Function Index scores, quality of life measures). Baseline laboratory values showing testosterone deficiency relative to female reference ranges, along with other relevant hormones. Previous treatment attempts and outcomes, demonstrating that standard approaches (counseling, alternative medications) proved insufficient. Peer-reviewed literature supporting off-label testosterone use in women for the specific indication—cite guidelines from professional organizations like the North American Menopause Society. Clinical rationale for the specific formulation requested, particularly if compounded (explain dosing precision requirements). Explicit statement that no FDA-approved alternative adequately addresses the patient's specific condition. The letter should be professional, concise, and evidence-based, positioning the prescription as medically necessary rather than elective. Prescription decisions are made solely by licensed medical professionals.

Is telehealth testosterone therapy more affordable than traditional treatment?

In many cases, yes—particularly when comparing total costs rather than just consultation fees. Traditional specialty care involves separate charges: endocrinology or gynecology consultations ($150-300 initial, $75-150 follow-up), laboratory testing coordinated through separate facilities, and retail compounding pharmacy prices. Total annual costs often reach $3,000-5,000. Telehealth platforms with integrated models bundle consultation, prescription management, lab coordination, and medication into transparent monthly fees, often reducing total expenditure by 30-40% through operational efficiency and negotiated pharmacy rates. Additionally, telehealth eliminates geographic barriers and travel costs, saving time and indirect expenses. The comparison grows more favorable for telehealth among patients with high-deductible insurance plans or those who've faced coverage denials, as the direct-pay model provides cost certainty that insurance-based care often lacks. Treatment outcomes vary by individual.