Testosterone (Injectable) Products
Defines Cigna coverage, prior authorization criteria, dosing, and coding for injectable testosterone products (Aveed, Azmiro, Testopel, Xyosted) including FDA-approved indications (male hypogonadism, delayed puberty) and treatment for gender dysphoria (FTM). Applies to health benefit plans administered by Cigna Companies subject to plan-level variances.
No criteria changes; minor policy format updates and addition of dosage form to products in the preferred product table.
Added Azmiro to the policy with the same criteria as other testosterone products.
Annual revision updated policy statement and employer/individual plan preferred product criteria and Conditions Not Covered statement.
Coding Information updated: added HCPCS J1072 and J1073 (note: J1073 effective 1/1/2026); updated S0189 description with effective-through date.