Aveed (testosterone undecanoate) precertification request form and coverage criteria
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Precertification request form and required clinical information for coverage review of Aveed (testosterone undecanoate injection) for Aetna members; used by prescribers/dispensing providers to request initiation or continuation of therapy.
No material clinical or coverage changes in this revision.
Coverage Criteria for Aveed (testosterone undecanoate)
Initial and continuation coverage criteria
Coverage review requires a completed precertification form with the following clinical confirmations:
See form sections A–F and acknowledgement
See clinical information sections
See clinical information: pre-treatment labs
See Depo‑Testosterone inquiry
See gender dysphoria and adolescent items
The precertification form separates general clinical items from questions specific to gender dysphoria and to patients younger than 18 years. When gender dysphoria is indicated, the form requires documentation that the prescriber is either a specialist in transgender youth care or is consulting with such a provider and that care has involved collaboration with a mental health provider. For adolescent patients the form also asks the prescriber to confirm the patient’s Tanner stage of puberty, that comorbid conditions are reasonably controlled, that the patient is able to make an informed decision about hormone therapy, that contraindications and side effects have been reviewed, and that fertility preservation options were discussed.
Initial Therapy
Initial Therapy
Initial therapy is covered when ALL of the following are met:
See clinical information
See clinical information: pre-treatment labs
See Depo‑Testosterone inquiry
Continuation Therapy
Continuation Therapy
For continuation requests, provide clinical information demonstrating ongoing benefit and safety:
See continuation request items
See continuation clinical information
Coding: Diagnosis and Procedure Codes
| Administration code(s) (CPT) | Form includes a field to provide administration CPT code(s). |
| Primary ICD Code | Field to indicate primary diagnosis ICD code for the request (e.g., hypogonadism or gender dysphoria). |
Provider Actions and Submission Requirements
Precertification required
Precertification is required for Aveed (testosterone undecanoate injection). The two‑page medication precertification request must be completed and legible; all fields on the form must be filled in for precertification review.
Prior testosterone therapy inquiry
The form asks whether the patient had an ineffective response, contraindication, or intolerance to Depo‑Testosterone and requires documentation of prior trial/response when applicable.
- Checkbox: Has the patient had an ineffective response, contraindication, or intolerance to Depo‑Testosterone? (Yes/No)
Required laboratory documentation
Attach a copy of the laboratory report showing at least two confirmed pre‑treatment low morning serum total testosterone concentrations based on reference lab range or current practice guidelines.
- Question on form: Did the patient have at least two confirmed pre‑treatment low morning serum total testosterone concentrations? (Yes/No/Unknown)
- Checkbox on form: Is the copy of the laboratory report with pretreatment morning serum total testosterone concentrations attached? (Yes/No)
Administrative documentation
Complete all administrative fields: patient demographics, insurance information, prescriber information (including licensure/NPI/DEA), dispensing provider and place of administration, and product/dose/frequency fields for precertification review.
- Patient information (name, DOB, contact, weight/height, allergies)
- Insurance information (Aetna Member ID, group, other coverage/IDs)
- Prescriber information (credential, address, phone, NPI, specialty)
- Dispensing/provider administration info (place of administration, administration CPT code(s), dispensing pharmacy details)
- Product information (Aveed dose and frequency)
Potential denial if information missing
The plan may request additional information or clarification to evaluate the request; incomplete or missing required clinical or administrative documentation (for example, pretreatment labs or required form fields) may lead to denial.
- Signature/date required on acknowledgment section.
- Failure to attach required clinical documentation (e.g., pretreatment morning testosterone labs) or to complete form fields may result in additional information requests or denial.
Key Definitions
Step Therapy / Prior Trial Requirements
| Step | Requirement |
|---|---|
| 1 | Form asks whether the patient had an ineffective response, contraindication, or intolerance to Depo‑Testosterone (Yes/No). |
Site of Administration
Specify site of care
Indicate the planned place of administration by selecting one of the acceptable options: self‑administered, physician's office, outpatient infusion center, or home infusion center.
- Provider may also indicate dispensing source: physician office, retail pharmacy, specialty pharmacy, or other.
- Form includes a field to provide administration CPT code(s).
Background
Aveed (testosterone undecanoate) is an injectable testosterone replacement therapy used for male hypogonadism and may be used as part of gender-affirming hormone therapy when clinically indicated. The precertification request form identifies the requested product as Aveed (testosterone undecanoate injection) and solicits the indication (e.g., primary hypogonadism, hypogonadotropic hypogonadism, age-related or late-onset hypogonadism, or gender dysphoria) along with product dose and frequency to support coverage review.
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