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Androderm — Blue Cross Blue Shield of Kansas

Gender Dysphoria / Gender Incongruence (gender-affirming hormone therapy, GAHT)

Initial criteria

  • For adults, ALL of the following must be met prior to initiating GAHT:
  • • Gender incongruence is marked and sustained
  • • Demonstrates capacity to consent for the specific gender-affirming hormone treatment
  • • Other possible causes of apparent gender incongruence have been identified and excluded
  • • Mental health and physical/medical conditions that could negatively impact the outcome of treatment have been assessed, with risks and benefits discussed
  • • Understands the effects and side effects of gender-affirming hormone treatment, including effects on reproduction, and they have explored reproductive options
  • For adolescents, ALL of the following must be met prior to initiating GAHT:
  • • The healthcare provider (HCP) has conducted a comprehensive biopsychosocial assessment, and included mental health and other medical professionals when required
  • • Involvement of parent(s)/guardian(s) in the assessment process, unless their involvement is determined to be harmful to the adolescent or not feasible
  • • Gender diversity/incongruence is marked and sustained over time
  • • Demonstrates the emotional and cognitive maturity required to provide informed consent/assent for treatment
  • • Mental health concerns (if any), physical/medical conditions, or social problems that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed sufficiently so that gender-affirming treatment can be provided optimally
  • • Informed of the effects (including irreversible) and side effects of treatment, including reproductive effects and fertility preservation options
  • • Patient age ≥ 16 years (may be started earlier in compelling cases, but generally not prior to age 13.5–14 years)
  • • Hormone therapy should not be initiated prior to the onset of endogenous puberty

Reauthorization criteria

  • Patients receiving testosterone should be evaluated for physical changes, adverse effects, and serum testosterone monitoring every 3 months during the first year or with dose changes.
  • Once a stable maintenance dose is reached with serum testosterone in the normal physiologic male range, evaluation and monitoring should occur once or twice yearly.
  • Dosing should be adjusted to maintain levels in the normal range for the individual’s gender identity.