Policy: Testosterone Enanthate Injection
Policy Number: 1015
Last Update: 2023-07-14
Next Update: 2024-04-25

Notes:

1. Gender dysphoria
   
   1. 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; or
         
   2. 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.