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Testosterone

DrugAndrogenic agents (topical testosterone)

November 2014

All products require prior authorization.

Preferred Products: Androderm, Androgel

Nonpreferred Products: Fortesta, Testim, Axiron, Testopel, Striant, Vogelxo

Approval criteria

  • Patient has a diagnosis of either primary hypogonadism or hypogonadotropic hypogonadism AND

Androderm/Androgel Criteria

  • Patient has had 2 early morning (prior to 10 a.m.) testosterone lab values that confirm low testosterone (<300ng/dL) within the past 18 months

Axiron, Fotesta, Striant, Testim, Testopel, Vogelxo Criteria

  • Patient has had 2 early morning (prior to 10 a.m.) testosterone lab values that confirm low testosterone (<300ng/dL) within the past 18 months AND
  • The patient has used at least Androgel 1% or 1.6% as replacement therapy without adequate testosterone response, as measured by laboratory testing

Note: Because testosterone is secreted in a pulsatile fashion, it is important to obtain 2 early morning testosterone levels. If the early morning testosterone level is at or below the lower limit of normal for the individual laboratory, then a repeat measurement of the early morning testosterone level should be performed to confirm the result and SHBG or a free testosterone level should be determined to assist in the diagnosis of a hypogonadal state.

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411

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