Methitest — Blue Cross Blue Shield of New Mexico

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
• ONE of the following:
• A. 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
• ONE of the following:
• A. Patient is an adolescent (≤17 years) AND meets state-specific continuation or initiation rules (not receiving treatment in restricted states; or qualifies under detailed Florida, Kentucky, North Carolina, North Dakota provisions) OR
• B. Patient is an adult (≥18 years) AND meets Florida, Alabama, or Puerto Rico age/consent requirements (Florida: written informed consent from in-person physician visit; Alabama: ≥19 years; Puerto Rico: ≥21 years) OR
• B. ALL of the following: patient has had clinical benefit AND ONE of the following:
• A. Diagnosis of primary or secondary hypogonadism AND current testosterone level within/below laboratory normal range or <300 ng/dL (total) or within/below normal (free) OR
• B. Diagnosis of gender dysphoria/gender incongruence WITH plan coverage for Gender Identity Disorder AND
• 1. If adult (≥18 years): monitored at least annually AND meets Florida/Alabama/Puerto Rico age and consent requirements AND testosterone level within/below range or support for ongoing therapy OR
• 2. If adolescent (≤17 years): monitored at least annually AND meets state-specific continuation provisions as above (not receiving treatment in restricted states; or qualifies under Florida, Kentucky, North Carolina, North Dakota, or Texas ASO continuation clauses) OR
• C. Patient has a diagnosis other than hypogonadism or gender dysphoria/gender incongruence AND patient has no FDA labeled contraindications AND
• If the request is for one of the listed brand agents, then ONE of the following:
• A. Use related to stage IV advanced, metastatic cancer treatment or associated condition; supported by literature; FDA approved OR
• B. Currently treated and stable on requested agent (chart notes) OR
• C. Tried and inadequate response to generic androgen/anabolic steroid supported for indication (chart notes) OR
• D. Generic discontinued due to lack of efficacy/effectiveness/diminished effect/adverse event (chart notes) OR
• E. Intolerance or hypersensitivity to generic not expected with brand (chart notes) OR
• F. FDA labeled contraindication to all generics not expected with brand (chart notes) OR
• G. Generic expected ineffective or unsuitable due to clinical or adherence reasons (chart notes) OR
• H. Generic not in best interest based on medical necessity (chart notes) OR
• I. Tried another drug in same class/MOA discontinued due to lack of efficacy/effectiveness/diminished effect/adverse event (chart notes) AND
• ONE of the following: patient not using in combination with another androgen/anabolic steroid OR support for multi-agent therapy

Approval duration

12 months