Aveed — Blue Cross Blue Shield of Kansas

Initial criteria

• The patient's current testosterone level meets ONE of the following: total serum testosterone within or below the laboratory's normal range for gender identity or <300 ng/dL OR free serum testosterone within or below the laboratory's normal range for gender identity.
• There is support for continuing therapy with the patient’s current testosterone level OR if the patient is an adolescent, the patient is being monitored at least once per year.
• The patient does NOT have any FDA labeled contraindications to the requested agent.
• If the request is for a listed brand agent, ONE of the following: (A) the patient has tried and had an inadequate response to a generic androgen or anabolic steroid agent supported for use for the requested indication OR (B) the patient has an intolerance or hypersensitivity to a generic androgen or anabolic steroid agent supported for use for the requested indication that is not expected to occur with the brand agent OR (C) the patient has an FDA labeled contraindication to ALL generic androgen or anabolic steroid agents supported for the requested indication that is not expected to occur with the brand agent.
• ONE of the following: (1) the patient will NOT be using the requested agent in combination with another androgen or anabolic steroid agent for the requested indication OR (2) there is support for therapy with more than one androgen or anabolic steroid agent.

Reauthorization criteria

• Continuation of therapy may be supported by current testosterone levels or documentation supporting benefit and continued need per initial criteria.

Approval duration

12 months