Policy: Testosterone Undecanoate Injection (Aveed)
Policy Number: 0528
Last Update: 2023-07-14
Next Update: 2024-04-25

Notes:

1. Gender dysphoria
   
   1. For continued treatment for gender dysphoria in members requesting reauthorization for gender dysphoria 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’s comorbid conditions are reasonably controlled; and
      4. The member has been educated on any contraindications and side effects to therapy; and
      5. Before the start of therapy, the member has been informed of fertility preservation options; or
   2. For continued treatment for gender dysphoria in adolescent members requesting reauthorization 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 previously 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. Before the start of therapy, the member has been informed of fertility preservation options.