Testosterone
Drug - Testosterone
January 2025
Preferred Drugs: Testosterone gel pump (Androgel), Testim
Nonpreferred Drugs: Testosterone gel (Fortesta), Testosterone (Testim), Testosterone gel (Vogelxo), Testosterone packet (Androgel), Testosterone gel pump (Axiron), Testopel, Vogelxo, Xyosted
Approval criteria
Preferred Drug Criteria
- Patient must have a diagnosis of primary hypogonadism or hypogonadotropic hypogonadism AND
- Patient has had 2 early morning (prior to 10 a.m.) testosterone lab values that confirm low testosterone (< 300 ng/dL) within the past 18 months
OR
- Patient must have clinical diagnosis of gender dysphoria AND
- Provider must provide documentation (chart notes, consultation notes, etc.) to substantiate all of the following:
- Any coexisting psychological, medical, or social problems that could interfere with treatment have been addressed and are reasonably controlled AND
- If the patient is 18 years of age or older, the patient has sufficient mental capacity to estimate the consequences of treatment, weigh benefits and risks AND
- The patient has been informed of effects and side effects of treatment (including potential loss of fertility and option to preserve fertility) AND
- The patient has given informed consent and, if under 18 years of age, parent(s) or guardian(s) have consented to treatment AND
- If patient is under 18 years of age, a pediatric endocrinologist or other clinician experienced in pubertal induction agrees with the indication for sex hormone treatment and that there are no medical contraindications
Nonpreferred Drug Criteria
- Patient must meet preferred drug criteria AND
- Patient has had adequate trial of the preferred products without adequate response
OR
- If the request is for Xyosted, the patient must:
- Meet preferred drug criteria AND
- Be under the age of 18 AND
- Be unable to accurately self-administer prescribed dosage of the preferred products
Billing for testosterone
Any testosterone formulation that requires administration by a healthcare provider must be billed as a medical claim.
Questions?
Provider Call Center 844-575-7887