Testosterone

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

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