- PA_APPLIES
- Preventive Drug: Zero copay. Grand Fathered Plans at Tier 2;
- 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
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