Policy: Testosterone Cypionate Injection (Depo-Testosterone)
Policy Number: 1014

Youth Services:

For gender dysphoria, the medication must be prescribed by or in consultation with a provider specialized in the care of transgender youth (e.g., pediatric endocrinologist, family or internal medicine physician, obstetrician-gynecologist) that has collaborated care with a mental health provider for members less than 18 years of age.

1. In an adolescent member when all of the following criteria are met:
   
   1. The member has a diagnosis of gender dysphoria; and
   2. The member is able to make an informed decision to engage in hormone therapy; and
   3. The member has reached Tanner stage 2 of puberty or greater; and
   4. The member’s comorbid conditions are reasonably controlled; and
   5. The member has been educated on any contraindications and side effects to therapy; and
   6. The member has been informed of fertility preservation options.

Notes:

When all of the following are met:

1. The member has a diagnosis of gender dysphoria; and
2. The member is able to make an informed decision to engage in hormone therapy; and
3. The member's comorbid conditions are reasonably controlled; and
4. The member has been educated on any contraindications and side effects to therapy; and
5. The member has been informed of fertility preservation options