Vogelxo (testosterone)
Hormones : Drugs for Men
  • Step Therapy: Low Testosterone:
    Step Applies
  • Quantity Limit: 2 packets (10 grams) per day
  • 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