Pharmacy Prior Authorization Criteria

Estrogen Products and Progesterone Product (Gender Dysphoria)

Indications for Prior Authorization

Criteria

Estrogen and Progesterone Products

Approval Length: N/A - Requests for gender transition or gender dysphoria should not be approved. Deny as a benefit exclusion. Certain Estrogen and Progesterone products may have existing drug-specific policies. Please reference the drug-specific policies first if it is available.

Non Formulary

Length of Approval: N/A - Requests for non-approvable diagnoses should not be approved
For diagnosis of Gender Dysphoria/Gender Incongruence (off-label)

• Requests for coverage for diagnoses of gender transition or gender dysphoria are not authorized and will not be approved

P & T Revisions

2025-12-05

References

---

Revision History

• 2025-12-05: Create Gender Dysphoria Exclusion Criteria

---