Skip to content
The Policy VaultThe Policy Vault

Fortesta — Blue Cross Blue Shield of Montana

secondary hypogonadotropic hypogonadism

Initial criteria

  • ONE of the following must be met:
  • 1. ALL of the following: requested indication is gender dysphoria/gender incongruence AND request is for a BCBS IL Fully Insured, HIM, or ASO/Self‑insured municipalities/counties/schools member AND regional/state exceptions apply by age and treatment status (see listed state restrictions for Alabama, Florida, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, North Carolina, North Dakota, Oklahoma, Puerto Rico, South Carolina, South Dakota, Tennessee)
  • OR 2. ALL of the following by product and diagnosis:
  • - Androgel, Aveed, Fortesta, Jatenzo, Kyzatrex, Natesto, Testim, testosterone topical solution, Tlando, Undecatrex, Vogelxo, or Xyosted: diagnosis of primary or secondary hypogonadism OR gender dysphoria/gender incongruence (plan covers Gender Identity Disorder)
  • - Azmiro, Depo‑Testosterone, or Testopel: diagnosis of primary or secondary hypogonadism OR delayed puberty in an adolescent OR gender dysphoria/gender incongruence (plan covers Gender Identity Disorder)
  • - Testosterone Enanthate intramuscular injection solution: diagnosis of primary or secondary hypogonadism OR delayed puberty in an adolescent OR breast cancer OR gender dysphoria/gender incongruence (plan covers Gender Identity Disorder)
  • - methyltestosterone or Methitest: diagnosis of primary or secondary hypogonadism OR breast cancer OR delayed puberty in an adolescent
  • AND one of the following clinical confirmations:
  • - For primary or secondary hypogonadism: patient shows signs/symptoms of hypogonadism AND two morning testosterone levels below lab normal range OR currently on therapy with low/normal testosterone levels (lab results required)
  • - For gender dysphoria/gender incongruence: diagnostic and consent requirements based on age (adolescent or adult), inclusion of comprehensive biopsychosocial assessment, involvement of parents/guardians when appropriate, informed consent/assent, maturity and mental health readiness, treatment location not restricted (see specified state restrictions)