| Anthem Blue Cross (HMO, PPO, EPO) |
| AndroGel 12.5 Mg/ 1.25 Gram (1 %) Glpm (testosterone) |
| Hormones : Drugs for Men |
- Low Testosterone:
Age Requirement: >= 18
Duration: 1 year(s)
Gender Requirement: Male
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: N/A
How Many Tests are Required to Confirm Diagnosis: = 2
Serum Total Testosterone Test Results: Unspecified
Free Testosterone Level Test Results: N/A
Patient must have symptoms of hypogonadism: Yes
Patient history of condition that may cause altered SHBG: No
Patient Must Not Have Untreated Sleep Apnea, Polycythemia or CHF: Yes
Supporting Documentation Requirements: Medical Tests
Diagnosis of Primary Hypogonadism or Hypogonadotropic Hypogonadisims: Yes
Documented Diagnosis: Yes
- Prior Authorization: Low Testosterone:
PA Applies
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