Androderm patch — Medical Mutual

Preferred products

• testosterone topical solution
• testosterone gel (generic products)

Initial criteria

• The patient has had persistent signs and symptoms (for example, depressed mood, decreased energy, progressive decrease in muscle mass, osteoporosis, loss of libido) of androgen deficiency (pre-treatment); AND
• The patient has had two pre-treatment serum testosterone measurements, each taken in the morning on two separate days AND both levels were low, as defined by the normal laboratory reference values; AND
• If the request is for Axiron, Natesto, Fortesta, Striant, or Vogelxo, the prescriber is verifying that the patient has tried one of the following: testosterone topical solution OR testosterone gel (generic products).

Reauthorization criteria

• The patient has had persistent signs and symptoms (for example, depressed mood, decreased energy, progressive decrease in muscle mass, osteoporosis, loss of libido) of androgen deficiency (pre-treatment); AND
• The patient has had at least one total serum testosterone level within the last 6 months within or below the normal limits of the reporting lab OR one total serum testosterone level beyond the normal limits, but the dose has been adjusted is required; AND
• If the request is for Axiron, Natesto, Fortesta, Striant, or Vogelxo, the prescriber is verifying that the patient has tried one of the following: testosterone topical solution OR testosterone gel (generic products).

Approval duration

1 year initial, 2 years reauth