Vogelxo — United Healthcare

Preferred products

• testosterone cypionate injection (generic Depo-Testosterone)
• testosterone enanthate injection

Initial criteria

• For Hypogonadism: Topical testosterone (gel, solution), testosterone transdermal systems (patches), and oral testosterone (capsules) approved if ANY of the following: (a) history of bilateral orchiectomy OR panhypopituitarism OR a genetic disorder known to cause hypogonadism (e.g., congenital anorchia, Klinefelter’s syndrome); OR (b) ALL of the following: (1) EITHER (a) two pre-treatment total testosterone levels <300 ng/dL or below reference range on separate days OR (b) BOTH condition causing altered SHBG (e.g., thyroid disorder, HIV, liver disorder, diabetes, obesity) AND one pre-treatment calculated free or bioavailable testosterone <50 pg/mL or below reference range; AND (2) not taking growth hormones (Genotropin, Humatrope, Norditropin FlexPro, Nutropin AQ, Omnitrope, Saizen) unless panhypopituitarism OR aromatase inhibitors (Arimidex, Femara, Aromasin); AND (3) patient was male at birth; AND (4) diagnosis of hypogonadism; AND (5) ONE of: significant weight reduction (<90% ideal body weight, e.g., AIDS wasting), osteopenia, osteoporosis, decreased bone density, decreased libido, or organic cause of testosterone deficiency (e.g., injury, tumor, infection, or genetic defect).
• For Hypogonadism: Xyosted requires EITHER (a) history of bilateral orchiectomy OR panhypopituitarism OR genetic disorder causing hypogonadism AND history of failure/contraindication/intolerance to testosterone cypionate and testosterone enanthate injections; OR (b) ALL of: (1) same testosterone level requirements as above; AND (2) not taking growth hormones listed above or aromatase inhibitors; AND (3) patient was male at birth; AND (4) diagnosis of hypogonadism; AND (5) one of: significant weight reduction (<90% ideal body weight), osteopenia, osteoporosis, decreased bone density, decreased libido, organic cause of testosterone deficiency; AND (6) history of failure/contraindication/intolerance to testosterone cypionate and testosterone enanthate injections.
• For Gender Dysphoria: Topical testosterone (gel, solution), testosterone transdermal systems (patches), and oral testosterone (capsules) approved if ALL of: (a) using hormones to change physical characteristics to align with gender expression; AND (b) diagnosed with gender dysphoria per current DSM; AND (c) not taking growth hormones listed (Genotropin, Humatrope, Norditropin FlexPro, Nutropin AQ, Omnitrope, Saizen) unless panhypopituitarism OR aromatase inhibitors (Arimidex, Femara, Aromasin).
• For Gender Dysphoria: Xyosted approved if ALL of: (a) using hormones to change physical characteristics to align with gender expression; AND (b) diagnosed with gender dysphoria per current DSM; AND (c) not taking growth hormones listed (Genotropin, Humatrope, Norditropin FlexPro, Nutropin AQ, Omnitrope, Saizen) unless panhypopituitarism OR aromatase inhibitors (Arimidex, Femara, Aromasin); AND (d) history of failure/contraindication/intolerance to testosterone cypionate and testosterone enanthate injections.

Reauthorization criteria

• Reauthorization approved if ANY of: (a) history of bilateral orchiectomy OR panhypopituitarism OR genetic disorder causing hypogonadism; OR (b) BOTH of the following: (1) EITHER (a) follow-up total serum testosterone within past 12 months within/below normal male limits OR (b) follow-up level outside upper male limits but dose adjusted OR (c) BOTH condition causing altered SHBG (e.g., thyroid disorder, HIV, liver disorder, diabetes, obesity) AND follow-up calculated free or bioavailable testosterone within/below normal male limits OR outside with dose adjusted; AND (2) not taking growth hormones (Genotropin, Humatrope, Norditropin FlexPro, Nutropin AQ, Omnitrope, Saizen) unless panhypopituitarism OR aromatase inhibitors (Arimidex, Femara, Aromasin).

Approval duration

12 months