- Quantity Limit: 3 bottles (21.96 grams) per month
- Prior Authorization: Low Testosterone:
PA Applies
- Low Testosterone:
Gender Requirement: Male
Medical Test Required: Yes
Reauthorization Required: No
Duration of Reauthorization: Unspecified
How Many Tests are Required to Confirm Diagnosis: = 3
Serum Total Testosterone Test Results: < 280
Free Testosterone Level Test Results: < 5
Patient must have symptoms of hypogonadism: Yes
Patient history of condition that may cause altered SHBG: Yes
Patient Must Not Have Untreated Sleep Apnea, Polycythemia or CHF: No
Diagnosis of Primary Hypogonadism or Hypogonadotropic Hypogonadisims: Yes
Documented Diagnosis: Yes
- Step Therapy: Low Testosterone:
Step Applies
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