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methyltestosterone capsule — Blue Cross Blue Shield of Illinois

Breast cancer

Initial criteria

  • Target Agent(s) will be approved when ONE of the following is met:
  • 1. ALL of the following:
  • A. The requested indication is gender dysphoria/gender incongruence AND
  • B. The request is for a BCBS IL Fully Insured, HIM, or ASO/Self-insured municipalities/counties/schools member AND
  • C. ONE of the following:
  • 1. The patient is an adolescent (age ≤ 17 years) and ONE of the following:
  • A. The patient is initiating sex hormone treatment AND The patient will NOT be receiving treatment in Alabama, Florida, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, North Carolina, North Dakota, Oklahoma, Puerto Rico, South Carolina, South Dakota, or Tennessee OR
  • B. The patient is continuing therapy with sex hormone treatment AND ALL of the following:
  • 1. The patient is NOT continuing treatment in Alabama, Idaho, Indiana, Iowa, Louisiana, Mississippi, Oklahoma, Puerto Rico, South Carolina, South Dakota, or Tennessee AND
  • 2. If the patient is continuing treatment in Florida, then treatment must have began prior to 05/17/23 with parental consent AND
  • 3. If the patient is continuing treatment in Kentucky, then the provider must have documented BOTH of the following:
  • A. Immediately terminating the minor's use of the treatment would cause harm to the patient AND
  • B. The provider has instituted a period of time where treatment is systematically reduced AND
  • 4. If the patient is continuing treatment in North Carolina, then treatment must have began prior to 08/01/2023 AND
  • 5. If the patient is continuing treatment in North Dakota, then treatment must have began prior to 04/21/2023 OR
  • 2. The patient is an adult (age ≥ 18 years) AND ALL of the following:
  • A. If the patient is receiving sex hormone treatment in Florida, then BOTH of the following:
  • 1. Written informed consent has been provided AND
  • 2. Consent was from an in-person physician visit AND
  • B. If the patient is receiving treatment in Alabama, then age ≥ 19 years AND
  • C. If receiving treatment in Puerto Rico, then age ≥ 21 years OR
  • 2. ALL of the following:
  • A. Diagnosis-dependent criteria as below:
  • 1. For Androgel, Aveed, Fortesta, Jatenzo, Kyzatrex, Natesto, Testim, testosterone topical solution, Tlando, Undecatrex, Vogelxo, or Xyosted: diagnosis of Primary or secondary (hypogonadotropic) hypogonadism OR Gender dysphoria/gender incongruence (plan covers Gender Identity Disorder) OR
  • 2. For Azmiro, Depo-Testosterone, or Testopel: diagnosis of Primary or secondary (hypogonadotropic) hypogonadism OR Delayed puberty in an adolescent OR Gender dysphoria/gender incongruence (plan covers Gender Identity Disorder) OR
  • 3. For testosterone enanthate intramuscular injection solution: diagnosis of Primary or secondary (hypogonadotropic) hypogonadism OR Delayed puberty in an adolescent OR Breast cancer OR Gender dysphoria/gender incongruence (plan covers Gender Identity Disorder) OR
  • 4. For methyltestosterone or Methitest: diagnosis of Primary or secondary (hypogonadotropic) hypogonadism OR Breast cancer OR Delayed puberty in an adolescent AND
  • B. ONE of the following:
  • 1. If request is for primary or secondary hypogonadism, then EITHER:
  • a. If not currently receiving testosterone, BOTH:
  • • Signs or symptoms of hypogonadism AND
  • • TWO morning serum testosterone levels below laboratory’s normal range (lab results required) OR
  • b. If currently receiving testosterone replacement therapy, current testosterone level is below or within normal range (lab results required) OR
  • 2. If request is for gender dysphoria/gender incongruence in adolescent (age ≤ 17 years), then ALL of the following:
  • A. Comprehensive biopsychosocial assessment by qualified physician and multidisciplinary consultation when required AND
  • B. Parents/guardians involved unless harmful or not feasible AND
  • C. Persistent diagnosis of gender dysphoria/gender incongruence sustained over time AND
  • D. ONE of the following: patient age ≥ 16 years OR documentation supporting initiation prior to 16 years AND
  • E. Counseling on irreversible effects, fertility impacts, and preservation options AND
  • F. Emotional and cognitive maturity for informed consent/assent AND
  • G. Informed consent/assent obtained (parental/guardian consent as applicable) AND
  • H. Coexisting mental/physical/social issues addressed AND
  • I. Patient is NOT BCBS TX ASO municipal/county/school member receiving treatment in Texas AND
  • J. Patient will NOT receive treatment in states where restricted: Alabama, Florida, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, North Carolina, North Dakota, Oklahoma, Puerto Rico, South Carolina, South Dakota, Tennessee.