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Fortesta — Blue Cross Blue Shield of Texas

stage four advanced metastatic cancer

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization process AND
  • ONE of the following:
  • A. For gender dysphoria/gender incongruence indications:
  • 1. The request is for a BCBS IL Fully Insured, HIM, or ASO/Self‑insured municipalities/counties/schools member AND
  • 2. ONE of the following:
  • A. The patient is ≤17 years (adolescent) AND conditions by state apply (restrictions or allowed continuation timelines as listed: Alabama, Florida, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, North Carolina, North Dakota, Oklahoma, Puerto Rico, South Carolina, South Dakota, Tennessee, Texas [for ASO municipalities/counties/schools])
  • B. The patient is ≥18 years (adult) AND must meet any applicable state‑specific age or consent requirements (Florida: written informed consent in person; Alabama ≥19 years; Puerto Rico ≥21 years)
  • B. The patient has had clinical benefit with the requested agent AND ONE of the following:
  • 1. Diagnosis of primary or secondary hypogonadism AND testosterone level ≤ normal laboratory range or <300 ng/dL (total) or within/below normal (free).
  • 2. Diagnosis of gender dysphoria/gender incongruence AND plan covers Gender Identity Disorder AND for adults (≥18 years): monitored at least annually AND meet applicable state requirements (Florida: in‑person consent; Alabama ≥19 years; Puerto Rico ≥21 years) AND serum testosterone within/below normal for gender identity or <300 ng/dL OR supported continuation.
  • 3. For adolescents (≤17 years): monitored at least annually AND adherence to state continuation restrictions (same as listed above, Florida/Kentucky/NC/ND/TX timelines).
  • C. The patient has a diagnosis other than the above but meets medical necessity requirements.
  • The patient has no FDA labeled contraindications to the requested agent.
  • If brand agents requested (listed drugs), then ONE of the following must apply:
  • A. Treatment for stage four metastatic cancer or associated condition consistent with best practices and supported by literature.
  • B. Patient currently stable on requested agent (chart notes required).
  • C. Tried and inadequate response to a generic androgen/anabolic steroid supported for indication (chart notes required).
  • D. Generic discontinued due to lack of efficacy/effectiveness/adverse event (chart notes required).
  • E. Intolerance or hypersensitivity to generic not expected with brand (chart notes required).
  • F. FDA labeled contraindication to all generics (chart notes required).
  • G. Generic expected ineffective or cause harm/barrier/comorbidity impact (chart notes required).
  • H. Generic not in best interest based on medical necessity (chart notes required).
  • I. Tried another drug of same class/MOA discontinued for lack of effect or AE (chart notes required).
  • The patient will not use the requested agent with another androgen/anabolic steroid for same indication OR support for dual therapy is documented.

Approval duration

12 months