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Undecatrex — Blue Cross Blue Shield of Oklahoma

Primary or secondary (hypogonadotropic) hypogonadism

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 the patient is continuing treatment in Florida, treatment must have begun prior to 05/17/23 with parental consent AND
  • 3. If the patient is continuing treatment in Kentucky, BOTH of the following: A. Immediately terminating treatment would cause harm AND B. A period of time is in place where treatment is systematically reduced AND
  • 4. If the patient is continuing treatment in North Carolina, treatment must have begun prior to 08/01/2023 AND
  • 5. If the patient is continuing treatment 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 receiving treatment in Florida: 1. The patient has provided written informed consent AND 2. Consent provided from in-person visit with physician AND
  • B. If receiving treatment in Alabama, the patient is age ≥ 19 years AND
  • C. If receiving treatment in Puerto Rico, the patient is age ≥ 21 years OR
  • 2. ALL of the following:
  • A. ONE of the following depending on drug requested:
  • • For Androgel, Aveed, Fortesta, Jatenzo, Kyzatrex, Natesto, Testim, testosterone topical solution, Tlando, Undecatrex, Vogelxo, Xyosted: patient has Primary or secondary (hypogonadotropic) hypogonadism OR Gender dysphoria/gender incongruence AND plan covers Gender Identity Disorder.
  • • For Azmiro, Depo-Testosterone, Testopel: patient has Primary or secondary (hypogonadotropic) hypogonadism OR Delayed puberty in an adolescent OR Gender dysphoria/gender incongruence AND plan covers Gender Identity Disorder.
  • • For testosterone enanthate intramuscular injection: patient has 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.
  • • For methyltestosterone or Methitest: patient has Primary or secondary (hypogonadotropic) hypogonadism OR Breast cancer OR Delayed puberty in an adolescent.
  • B. ONE of the following:
  • 1. If request is for primary or secondary hypogonadism, then:
  • A. ONE of the following:
  • 1. If NOT currently receiving testosterone therapy: BOTH of the following required:
  • A. Patient has sign or symptom of hypogonadism AND
  • B. Two pretreatment or current morning (7–11am) serum testosterone levels on separate days below normal range (lab results required).
  • 2. If currently receiving testosterone therapy: patient’s current total or free serum testosterone level is below or within normal range (lab results required).
  • 2. If request is for gender dysphoria/gender incongruence, then ONE of the following:
  • A. The patient is an adolescent (age ≤ 17 years) and ALL of the following:
  • • Comprehensive biopsychosocial assessment performed by qualified physician and prescriber consults as needed.
  • • Parents or guardians involved unless involvement is harmful or not feasible.
  • • Persistent gender dysphoria/gender incongruence diagnosis marked and sustained over time.
  • • Patient is age ≥ 16 years OR therapy initiation supported prior to 16 years.
  • • Patient counseled on irreversible effects, fertility impact, and preservation options.
  • • Patient has sufficient maturity for informed consent/assent.
  • • Patient and, as applicable, parents/guardians provided consent.
  • • Coexisting mental or physical conditions addressed for optimal treatment.
  • • Patient is NOT BCBS TX ASO municipalities/counties/schools member receiving treatment in Texas.
  • • 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.