Health Net
Vogelxo Pump (testosterone)
Hormones : Drugs for Men
  • Prior Authorization: Low Testosterone:
    PA Applies
  • Low Testosterone:
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    How Many Tests are Required to Confirm Diagnosis: >= 2
    Serum Total Testosterone Test Results: < 300
    Free Testosterone Level Test Results: N/A
    Patient must have symptoms of hypogonadism: No
    Patient history of condition that may cause altered SHBG: No
    Patient Must Not Have Untreated Sleep Apnea, Polycythemia or CHF: No
    Supporting Documentation Requirements: 2 of Chart Notes;Lab Tests
    Reauthorization Supporting Documentation Requirements: Successful response to therapy
    Diagnosis of Primary Hypogonadism or Hypogonadotropic Hypogonadisims: Yes
    Documented Diagnosis: Yes

  • Step Therapy: Low Testosterone:
    Step Applies