Drug - Androgenic agents (topical testosterone)
All products require prior authorization.
Preferred Products: Androderm, Androgel
Nonpreferred Products: Fortesta, Testim, Axiron, Testopel, Striant, Vogelxo
- Patient has a diagnosis of either primary hypogonadism or hypogonadotropic hypogonadism AND
- 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.
MHCP Provider Call Center 651-431-2700 or 800-366-5411