Notification of Drug Policy Revisions Effective April 1, 2024 (Posted February 1, 2024)

Medical Drug Policy Name	Revised Criteria
Testosterone Pellet Implantation for Androgen Deficiency Notification (PDF)	Added requirement for submission of laboratory values for HIV indication with low testosterone levels. Added the following note within policy, “Hormone pellet implantation (e.g., testosterone pellets) is considered investigational for hormone replacement therapy to treat menopause related symptoms. BCBSNC does not provide coverage for investigational services or procedures.”Added requirement for submission of laboratory values for HIV indication with low testosterone levels. Added the following note within policy, “Hormone pellet implantation (e.g., testosterone pellets) is considered investigational for hormone replacement therapy to treat menopause related symptoms. BCBSNC does not provide coverage for investigational services or procedures.” Added requirement for submission of laboratory values for HIV indication with low testosterone levels. Added the following note within policy, “Hormone pellet implantation (e.g., testosterone pellets) is considered investigational for hormone replacement therapy to treat menopause related symptoms. BCBSNC does not provide coverage for investigational services or procedures.” Policy notification given 2/1/2024 for effective date 4/1/2024.

Medical Drug Policy Name

Revised Criteria

Testosterone Pellet Implantation for Androgen Deficiency Notification (PDF)

Added requirement for submission of laboratory values for HIV indication with low testosterone levels. Added the following note within policy, “Hormone pellet implantation (e.g., testosterone pellets) is considered investigational for hormone replacement therapy to treat menopause related symptoms. BCBSNC does not provide coverage for investigational services or procedures.”Added requirement for submission of laboratory values for HIV indication with low testosterone levels. Added the following note within policy, “Hormone pellet implantation (e.g., testosterone pellets) is considered investigational for hormone replacement therapy to treat menopause related symptoms. BCBSNC does not provide coverage for investigational services or procedures.” Added requirement for submission of laboratory values for HIV indication with low testosterone levels. Added the following note within policy, “Hormone pellet implantation (e.g., testosterone pellets) is considered investigational for hormone replacement therapy to treat menopause related symptoms. BCBSNC does not provide coverage for investigational services or procedures.” Policy notification given 2/1/2024 for effective date 4/1/2024.

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