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Drug - Testosterone

August 2019

Preferred Drugs: Androderm, Androgel

Nonpreferred Drugs: Axiron, Fortesta, Striant, Testim, 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


  • Patient must have clinical diagnosis of gender dysphoria as confirmed by a mental health provider 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


  • 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.


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

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