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Depo-Testosterone — Blue Cross Blue Shield of Texas

Breast cancer

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 age or state-based criteria are met for adolescent (<18 years) or adult (≥18 years) patients as detailed in policy.
  • 2. ALL of the following: (A) Indication and drug-specific diagnosis criteria:
  • • If 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 (and plan covers Gender Identity Disorder).
  • • If Azmiro, Depo-Testosterone, or Testopel → diagnosis of primary or secondary hypogonadism OR delayed puberty in adolescents OR gender dysphoria/gender incongruence (and plan covers Gender Identity Disorder).
  • • If testosterone enanthate intramuscular injection solution → diagnosis of primary or secondary hypogonadism OR delayed puberty in adolescents OR breast cancer OR gender dysphoria/gender incongruence (and plan covers Gender Identity Disorder).
  • • If methyltestosterone or Methitest → diagnosis of primary or secondary hypogonadism OR breast cancer OR delayed puberty in adolescents.
  • (B) Additional diagnostic support for hypogonadism: TWO morning serum testosterone levels below normal range OR current testosterone therapy with serum level below or within normal lab range.
  • (C) If indication is gender dysphoria/gender incongruence, additional age-appropriate clinical, consent, and psychosocial assessment requirements as specified for adolescents and adults must be met.