Xyosted — Highmark
Primary or secondary hypogonadism with testicular failure due to double orchidectomy
Preferred products
- generic methyltestosterone capsules
- generic testosterone topical product
Initial criteria
- Member is male
- Diagnosis of primary or secondary hypogonadism with testicular failure (ICD-10: E29.1) due to double orchidectomy
- If request is for brand Methitest, member has experienced therapeutic failure or intolerance to plan-preferred generic methyltestosterone capsules
- If request is for brand Androgel 1%, Androgel 1.62%, Fortesta, Testim, Vogelxo, Natesto, Jatenzo, Tlando, Kyzatrex, Undecatrex, or Xyosted, member has experienced therapeutic failure or intolerance to one plan-preferred generic testosterone topical product
Reauthorization criteria
- Prescriber attests member has experienced positive clinical response to testosterone therapy
- Member requires continued therapy with a testosterone product
Approval duration
12 months