Methitest — Highmark

chronic steroid treatment

Preferred products

Member is male
Diagnosis of hypogonadism (ICD-10: E29.1)
Meets at least one of the following: primary or secondary hypogonadism with testicular failure due to bilateral torsions, chemotherapy damage, cryptorchidism, Klinefelter's syndrome, orchitis, radiation damage, single orchidectomy, surgery damage, toxic damage, or vanishing testis syndrome OR primary or secondary hypogonadism in males with symptoms of low testosterone OR secondary hypogonadism due to hypopituitarism OR weight loss due to HIV-infection OR chronic steroid treatment
Provider submits documentation of low pre-treatment testosterone supported by two morning total testosterone levels <264 ng/dL or below lab normal range OR two morning total testosterone levels <300 ng/dL and free testosterone <65 pg/mL OR member not producing any testosterone OR, if records unavailable, provider attests to at least one low pretreatment testosterone level <300 ng/dL
Provider submits testosterone level within past 12 months showing either within normal limit (300–1000 ng/dL) OR out of normal limit and dosage being adjusted
If request is for brand Methitest, must have therapeutic failure or intolerance to plan-preferred generic methyltestosterone capsules
If request is for specific brands (Androgel 1%, Androgel 1.62%, Fortesta, Testim, Vogelxo, Natesto, Jatenzo, Kyzatrex, Tlando, Undecatrex, Xyosted), must have therapeutic failure or intolerance to one plan-preferred generic testosterone topical product

Prescriber attests member has experienced positive clinical response to testosterone therapy
Member requires continued therapy with a testosterone product
Provider submits testosterone level within past 12 months showing either within normal limit (300–1000 ng/dL) OR out of normal limit and dosage being adjusted

12 months