CurrentCignaPolicy v111525

Testopel (testosterone pellets) prior authorization

This document is a Cigna prior authorization form and instructions for coverage review of Testopel (testosterone pellets). It governs requests for prescription/medical benefit coverage and affects prescribers, office staff, and pharmacy/infusion providers submitting authorization for members.

Policy Summary

PayerCigna

PolicyTestopel (testosterone pellets) prior authorization

Policy CodePolicy v111525

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit the prior authorization form with required diagnosis, documentation of signs/symptoms, and pre-treatment serum testosterone measurements as specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

Testopel 75mgmedication on form

Accredopreferred specialty pharmacy

855-840-1678fax to submit

800-882-4462urgent phone

Coverage Criteria

Prior Authorization Clinical Criteria

Authorization is supported when documentation provided on the form meets diagnosis selection and pre-treatment testing/clinical criteria as applicable.

Allowed Indications: One of the following diagnosis boxes must be selected: Hypogonadism (Primary or Secondary) in Males; Delayed Puberty or Induction of Puberty in Males; Gender-Dysphoric/Gender-Incongruent Persons undergoing FTM gender reassignment; other indications.

Form includes explicit options 'To Enhance Athletic Performance' and 'none of the above' which inform review; selection of those may lead to non-coverage.

Hypogonadism-specific requirements: For hypogonadism: documentation of persistent signs and symptoms of androgen deficiency (e.g., depressed mood, decreased energy, progressive decrease in muscle mass, osteoporosis, loss of libido).

Form asks yes/no to presence of persistent signs/symptoms and requests timing relative to initiation of therapy.

The prior authorization form lists diagnosis options that direct clinical review. Authorization is supported when the documentation submitted on the form matches one of the permitted indications (for example, Hypogonadism (Primary or Secondary) in Males, Delayed Puberty or Induction of Puberty in Males, or Gender‑Dysphoric/Gender‑Incongruent persons undergoing FTM gender reassignment) and the applicable pre‑treatment testing and clinical criteria are provided. The form specifically includes selection boxes for To Enhance Athletic Performance and none of the above; choosing either of these non‑therapeutic options informs reviewers that the request does not meet the therapeutic diagnostic categories listed and may affect coverage determination.

Policy Summary

PayerCigna

PolicyTestopel (testosterone pellets) prior authorization

Policy CodePolicy v111525

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionComplete and submit the prior authorization form with required diagnosis, documentation of signs/symptoms, and pre-treatment serum testosterone measurements as specified.

SourceLink

On This Page

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Indications selected solely to To Enhance Athletic Performance are identified on the form as a non‑therapeutic purpose. Selection of this option (or none of the above) signals that the request is outside the stated therapeutic indications and may be deemed not medically necessary during prior authorization review.

Coding

Covered drug requestNDC|brand

Testopel 75mg

medication requested (as listed on form)

Provider Actions & Submission Instructions

Prior Authorization

Prior Authorization Required

Prior authorization is required for Testopel (testosterone pellets). Requests must be submitted using the prior authorization form and can be sent online at www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR. Fax submission is available per the form instructions. Our standard response time for prescription drug coverage requests is 5 business days; if urgent, call to expedite.

Submit via CoverMyMeds online or SureScripts in EHR
Fax submission available per form instructions
Standard response time: 5 business days; call if urgent

Documentation Required

Documentation of Pre-treatment Testing

The form requires documentation of pre-treatment signs/symptoms and serum testosterone testing as applicable. For patients with hypogonadism who are initiating therapy, two pre-treatment serum testosterone (total or bioavailable) measurements are required, each taken in the early morning on separate days, and both must be low per the laboratory reference range. For patients currently receiving testosterone therapy, at least one pre-treatment serum testosterone (total or bioavailable) level with a low result is required. The form defines the pre-treatment timeframe as signs/symptoms and testosterone levels prior to initiation of any testosterone therapy.

Initial therapy: TWO early-morning serum testosterone measurements on two separate days; both must be low per lab reference
Currently receiving therapy: at least ONE pre-treatment serum testosterone level with a low result
Pre-treatment signs/symptoms of androgen deficiency must be documented (e.g., depressed mood, decreased energy, decreased muscle mass, osteoporosis, loss of libido)

Documentation Required

Required Documentation on Form

The prior authorization form must include completed patient and prescriber information, diagnosis selection, and clinical information (including gender/specialist consultation question and whether therapy is initial or patient is currently receiving testosterone therapy). All asterisked (*) items on the form must be completed for the Health Plan to respond via fax. Additional required elements include urgency selection, medication requested, dosing, duration, frequency, ICD-10 code, and any additional pertinent information or attestations. Prescriber signature and date are required.

Complete all asterisked (*) patient and prescriber fields (e.g., Physician Name, DEA/NPI/TIN, Patient Name, Cigna ID, DOB, Patient Address, Patient Phone)
Include urgency (standard or urgent), medication requested, dosing, duration, frequency, and ICD-10
Indicate whether prescribed by or in consultation with an endocrinologist or physician specializing in transgender care
Specify if therapy is initial or patient is currently receiving testosterone therapy
Provide clinical information, pre-treatment testing results as applicable, additional pertinent information, prescriber attestation, signature, and date

Definitions

Pre‑treatment timeframe — key definitions

DefinitionPre-treatment timeframe = the period referring to signs and symptoms of androgen deficiency and serum testosterone levels prior to the initiation of any testosterone therapy.

Initial therapy requirementTwo pre-treatment serum testosterone (total or bioavailable) measurements, each taken in the early morning on two separate days (both must be low per lab reference ranges).

Continuation therapy requirementAt least one pre-treatment serum testosterone (total or bioavailable) level with a low result as defined by laboratory reference values.

Clinical signs referencedSigns and symptoms include depressed mood, decreased energy, progressive decrease in muscle mass, osteoporosis, and loss of libido.

Form attestation noteThe pre-treatment timeframe language appears repeatedly on the form to clarify that testing and symptoms are from before initiation of any testosterone therapy.

Initial Therapy Criteria

Initial Therapy

For patients initiating testosterone pellet therapy.

Initial therapy testing: Form requires TWO pre-treatment serum testosterone (total or bioavailable) measurements, each taken in the early morning on two separate days.two morning tests

The form requests that both morning measurements be documented as low per the laboratory reference ranges.

Documentation of signs/symptoms: Document persistent signs and symptoms of androgen deficiency prior to initiation of any testosterone therapy.

The 'pre-treatment timeframe' refers to signs/symptoms and serum testosterone levels prior to initiation of therapy.

Continuation Therapy Criteria

Continuation Therapy

For patients currently receiving testosterone therapy.

Continuation therapy documentation: Indicate 'Currently receiving Testosterone Therapy' and provide at least ONE pre-treatment serum testosterone (total or bioavailable) with a low result as defined by laboratory reference values.one prior low test

Form distinguishes initial vs continuation therapy and requests the single prior low pre-treatment value for those currently receiving therapy.

Documentation of signs/symptoms: Document that the patient had persistent signs and symptoms of androgen deficiency in the pre-treatment timeframe.

Pre-treatment timeframe refers to signs/symptoms and serum testosterone levels prior to initiation of any testosterone therapy.

Step Therapy / Prior Authorization Pathways

Therapy status	Form selection
{"text":"Initial therapy","status":""}{"text":"Form includes a checkbox asking whether this is 'Initial therapy' (provider selects if the patient is starting testosterone pellet therapy).","status":""}
{"text":"Currently receiving Testosterone Therapy","status":""}{"text":"Form includes a checkbox for 'Currently receiving Testosterone Therapy' to indicate continuation of treatment. This selection may inform review or step/prior authorization pathways.","status":""}
{"text":"None of the above","status":""}{"text":"Form includes 'None of the above' as an option when initial vs continuation therapy does not apply.","status":""}

Site of Care / Dispensing Options

Note

Indicate site of care and dispensing source (Accredo, office stock, retail, home infusion)

Specify where the medication will be obtained on the form; options include Accredo (Cigna's nationally preferred specialty pharmacy), prescriber's office stock (medical claim), retail pharmacy, or home infusion/vendor, and facility dispensing details are requested if office-dispensed.

Select 'Accredo Specialty Pharmacy' to use the nationally preferred specialty pharmacy (Accredo contact details provided).
If prescriber's office stock will be used, provide facility name, tax ID, address, and indicate billing on a medical claim form.

Background

Testopel is listed on the form as the requested implantable testosterone product. The diagnosis choices clarify that testosterone pellets are intended for therapeutic uses such as male hypogonadism, induction of puberty or delayed puberty in males, and gender‑affirming masculinization for FTM patients. The form therefore frames Testopel as a prescription treatment for those clinical indications and distinguishes therapeutic use from non‑therapeutic purposes like enhancing athletic performance.