Testosterone Enanthate intramuscular injection solution — Blue Cross Blue Shield of New Mexico

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 in Florida, treatment must have begun prior to 05/17/23 with parental consent AND (3) If in Kentucky, documentation of BOTH: (A) immediate termination would cause harm AND (B) therapy is being systematically reduced AND (4) If in North Carolina, treatment must have begun prior to 08/01/2023 AND (5) If in North Dakota, treatment must have begun prior to 04/21/2023 OR 2. The patient is an adult (age ≥ 18 years) AND ALL of the following: (A) If in Florida, patient has provided written informed consent at in-person physician visit AND (B) If in Alabama, patient is age ≥ 19 years AND (C) If in Puerto Rico, patient is age ≥ 21 years.
• 2. ALL of the following: A. ONE of the following indication/product relationships: (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 AND plan covers Gender Identity Disorder. (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 AND plan covers Gender Identity Disorder. (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 AND plan covers Gender Identity Disorder. (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) For primary or secondary hypogonadism: (A) If NOT currently receiving testosterone replacement therapy, BOTH: (1) presence of sign or symptom of hypogonadism AND (2) TWO morning (7–11 am) serum testosterone levels on separate days below lab normal range [lab results required] OR (B) If currently receiving therapy, current free or total testosterone below or within lab normal range [lab results required]. (2) For gender dysphoria/gender incongruence: (A) If adolescent (≤ 17 years) and initiating sex hormone treatment, ALL of: (1) comprehensive biopsychosocial assessment by qualified physician with consultation as required; (2) parental/caregiver involvement unless harmful/not feasible; (3) persistent diagnosis sustained over time; (4) patient age ≥ 16 years OR supported initiation before 16; (5) counseling on irreversible effects, fertility impact, fertility preservation options; (6) sufficient maturity for informed consent/assent; (7) informed consent/assent obtained from patient and guardians as applicable; (8) coexisting health/social problems addressed; (9) patient is NOT BCBS TX ASO municipalities/counties/schools member in Texas; (10) patient will NOT be treated in Alabama, Florida, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, North Carolina, North Dakota, Oklahoma, Puerto Rico, South Carolina, South Dakota, or Tennessee.