CurrentAetnaPolicy N/A

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.

Policy Summary

PayerAetna

PolicyAveed (testosterone undecanoate) precertification request form and coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit the two‑page precertification form with all clinical fields and attach two confirmed pre-treatment morning total testosterone lab reports.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

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CurrentAetnaPolicy N/A

Aveed (testosterone undecanoate) precertification request form and coverage criteria

Customize your policy alerts

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Know when Aetna releases new policies or updates existing guidance.

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Policy Summary

PayerAetna

PolicyAveed (testosterone undecanoate) precertification request form and coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit the two‑page precertification form with all clinical fields and attach two confirmed pre-treatment morning total testosterone lab reports.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

Coverage Criteria for Aveed (testosterone undecanoate)

Initial and continuation coverage criteria

Coverage review requires a completed precertification form with the following clinical confirmations:

Documentation and administrative data: Patient demographics, insurance information, prescriber and dispensing provider details, product dose and frequency, and signature/date must be provided on the form.

See form sections A–F and acknowledgement

Diagnosis: Requested indication must be specified (primary hypogonadism, hypogonadotropic hypogonadism, age-related/late-onset hypogonadism, gender dysphoria, or other).

See clinical information sections

Baseline testosterone confirmation: Prior to initiating therapy the patient must have at least two confirmed pre-treatment low morning serum total testosterone concentrations based on reference lab range or current practice guidelines, and a copy of the laboratory report should be attached to the request.2 low morning total testosterone values

See clinical information: pre-treatment labs

Prior therapy or intolerance: Form documents whether the patient had an ineffective response, contraindication, or intolerance to Depo-Testosterone; provide details if applicable.

See Depo‑Testosterone inquiry

Gender dysphoria / adolescent-specific requirements: If the request is for gender dysphoria or for a patient <18 years, confirm age, Tanner stage, that the drug is prescribed by or in consultation with a provider specialized in transgender youth (or equivalent) with documented collaboration with a mental health provider, that comorbid conditions are reasonably controlled, informed consent and education on risks/contraindications occurred, and that fertility preservation options were discussed.

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 is covered when ALL of the following are met:

Initial therapy requirements: Documented diagnosis (selecting primary hypogonadism, hypogonadotropic hypogonadism, age-related/late-onset hypogonadism, gender dysphoria, or other) is provided on the form.

See clinical information

Baseline laboratory confirmation: At least two confirmed pre-treatment low morning serum total testosterone concentrations are documented based on reference lab range or current practice guidelines, and the laboratory report is attached to the request.2 low morning total testosterone values

See clinical information: pre-treatment labs

Prior trial of Depo-Testosterone when applicable: If applicable, documentation that the patient had an ineffective response, a contraindication to, or intolerance of Depo‑Testosterone is provided on the form.

Continuation Therapy

For continuation requests, provide clinical information demonstrating ongoing benefit and safety:

Continuation documentation: Date of last treatment, indication, current diagnosis and gender information, and documentation of ongoing clinical benefit and safety must be provided; indicate if the patient is receiving samples or manufacturer assistance.

See continuation request items

Prior baseline confirmation may be required: Confirm that prior to the start of therapy the patient had at least two confirmed low morning serum total testosterone concentrations based on reference lab range or practice guidelines; indicate whether pre-treatment lab reports are on file.2 low morning total testosterone values (may be required)

See continuation clinical information

Coding: Diagnosis and Procedure Codes

Administration CPT codes (provider to supply)CPT

Administration code(s) (CPT)

Form includes a field to provide administration CPT code(s).

Diagnosis codesICD-10

Primary ICD Code

Field to indicate primary diagnosis ICD code for the request (e.g., hypogonadism or gender dysphoria).

Provider Actions and Submission Requirements

Prior Authorization

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.

Step Therapy

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)

Key Definitions

Confirmed low morning serum total testosterone

Required confirmationAt least two confirmed pre-treatment low morning serum total testosterone concentrations based on reference lab range or current practice guidelines must be documented prior to initiating therapy.

Timing of measurementsMeasurements must be morning serum total testosterone values (pre-treatment).

Documentation to attachAttach copy of the laboratory report with the pretreatment morning serum total testosterone concentrations to the precertification request.

Response options on formForm includes checkboxes for Yes / No / Unknown to indicate whether the two confirmed pre-treatment low morning morning serum total testosterone values are present.

Applies to initiation and continuationQuestion appears prior to initiating therapy and continuity requests note that clinical documentation is required (baseline labs may be requested for continuation).

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

Note

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.