- 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
- Prior Authorization: Low Testosterone:
PA Applies
- Step Therapy: Low Testosterone:
Step Applies
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