Drug Reference for Care This is a summary of medications covered under SelectHealth specific to Transgender Care. Please refer to the SelectHealth formulary for a complete list of covered drugs.

Endocrine Treatment of An Endocrine Society regimens Gender-Dysphoric Persons: Clinical Practice Guideline SelectHealth in adult transgender Dose Range An Endocrine Society Recommendations Comment Formulary persons Clinical Practice Guideline (Adolescents) Increase Status Recommendations (Adults) dose every 6 months 5 ug/kg/day 10 ug/kg/day Oral: 2 to 6 mg/day 2 to 6 mg/day Covered 15 ug/kg/day 20 ug/kg/day 0.1 to 0.4 mg/24h, 6.25 to 12.5 ug/24h Lower risk of Transdermal: estradiol changed twice 0.025 to 0.2 mg/day 25 ug/24h thromboembolism compared Covered patch weekly 37.5 ug /24h with oral estrogen option Injectable: estradiol 5 to 20 mg IM Abuse potential; due to 5-30 mg IM every 2 weeks valerate every 2 weeks prolonged time to onset Covered

Trans Women Trans of effect and steady-state, Injectable: estradiol 2 to 10 mg IM 2-10 mg IM every week greater risk of accumulation Covered cypionate every week and overdose Oral: progesterone 20-60 mg PO daily Covered Injectable: 150 mg IM every medroxyprogesterone Covered: 3 months acetate 1 in 84 days Implant: 50 mg implanted Expensive; used in youth as Covered: PA (Supprelin LA) every 12 months a blocker Oral: 250 mg 3x daily Higher risk of hepatotoxicity Covered

IM: intramuscular; GnRH agonist: -releasing hormone agonist; PA: Prior Authorization; FE: Formulary exception - A request to the plan to consider a change in coverage rules based on an individual’s medical necessity. Hembree W., Cohen-Kettenis T, Gooren L. Endocrine Treatment of Gender- Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2017;102(11):3869-3903. Access at: https://academic.oup.com/jcem/article/102/11/3869/4157558 “Progress” Pride Flag by Daniel Quasar (quasar.digital LLC) Trans Men Trans Women (Zoladex, Zoladex LA) Zoladex (Zoladex, pellets (Testopel) pellets Implant: unde testosterone cypionate testosterone or enanthate testosterone Injectable: Eligard) Depot, (Lupron leuprolide Injectable: Oral:finasteride spironolactone Oral: (Androderm) testosterone patch Transdermal: testosterone gel 1% Transdermal: Injectable: (Trelstar, Triptodur) Injectable: testosterone testosterone in adulttransgender Testosterone GnRH agonist Antiandrogens (cont.) Hormone regimens canoate (Aveed) persons

implant monthly 3.6 mg SQ orally mg/day100 to 400 12 weeks 12 testosterone) mg/day 100 to 25 mg to gel/day (equivalent depot monthly 1000 mg every mg every 1000 75 mg/pellet IM every 2weeks IM every 100 mg to 200 every week OR every 50 to 100 mg IM depot monthly 3.75 to 7.5 mg IM orally 2.5 to 5mg/day transdermal 2.5 to 7.5 mg/day 2.5 to 10 gof 3.75 mg IM Dose Range

12 weeks 12 mg every 1000 1.6% gel –50-100 mg/day 11.25 mg 3months SQ every 3.75 mg SQ monthly; 11.25 mg 3months SQ every 3.75 mg SQ monthly; 2 weeks or2 weeks 50% week per 100 mg IM every –200 11.25 mg 3months SQ every 3.75 mg SQ monthly; 2.5 7.5 – mg/day Gender-Dysphoric Persons: Recommendations (Adults Clinical Practice Guideline 100-300 mg/day100-300 Endocrine Treatment of An Endocrine Society An EndocrineSociety

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50 mg/m50 25 mg/m 25 75 mg/m 75 100 mg/m 100 Clinical Practice Guideline (Adolescents) Increase An Endocrine Society An EndocrineSociety dose every 6months Recommendations 2 2 2 /2 weeks /2 /2 weeks /2 /2 weeks /2 2 /2 weeks /2

occurs before fullyoccurs dried contact if transfer interpersonal formulations result can in preparations;injectable gel than levels testosterone variationLess in serum male pattern baldness male pattern and electrolytes and Monitor pressure blood as a puberty blocker as apuberty Expensive; in youth used Expensive occur might site reactions injection (e.g.,variation in effect mood); peak-produce less trough Weekly injections secretion gonadotropin Inhibits Possible add-on to slow to slow Possible add-on compared gels with levels and irritation more skin lowerMay serum produce

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Last Updated: 10/2020 Covered Covered FE request covered; Not Covered: PA Covered: PA Covered: Covered: PA Covered: PA Covered: PA Covered: PA Covered: SelectHealth SelectHealth Formulary Formulary Status