Androgenic Agents, Topical (Testosterone) Prior Authorization
Customize your policy alerts
Sign up for all Georgia Department of Community Health policy alerts
Know when Georgia Department of Community Health releases new policies or updates existing guidance.
Monitor payer policy activity
This policy governs prior authorization requirements for topical androgenic (testosterone) products for Georgia Medicaid Fee-for-Service members, specifying clinical criteria and documentation needed for coverage of preferred and non-preferred topical testosterone formulations.
No material clinical or coverage changes in this revision.
Coverage Criteria for Topical Testosterone
Androgel 1.62% and 1.62% generic approval
Covered when ALL of the following are met
Applies to Androgel 1.62% and testosterone transdermal gel pump 1.62% generic
Non-preferred topical testosterone
Covered with additional requirement
Applies to Natesto, testosterone transdermal gel generic (Fortesta, Testim, Vogelxo) and testosterone transdermal solution generic
Exceptions to the coverage criteria may be considered on a case-by-case basis through the prior authorization process. Providers may initiate the prior authorization review by contacting OptumRx at the phone number provided in the policy.
Use of topical testosterone for diagnoses other than primary or secondary hypogonadism, or in the absence of required laboratory and age documentation, does not meet the policy criteria for coverage. Specifically, coverage for preferred 1.62% formulations requires the member to be male and ≥ 18 years with serum testosterone < 300 ng/dL confirmed by two separate morning blood samples on different days; non-preferred topical products additionally require a written letter of medical necessity from the prescriber explaining why preferred products are not appropriate.
Initial Topical Testosterone Therapy
Initial topical testosterone therapy
Initial authorization criteria
Length of authorization: 6 months
Prescriber letter required
Provider Actions and Prior Authorization Requirements
Prior authorization required; 6-month authorization
Prior authorization is required for both preferred and non-preferred topical testosterone products. The length of authorization is 6 months and clinical criteria must be met for approval.
Step/step-down: preferred-product trial or justification required
Non-preferred topical testosterone products will only be covered if the member meets the preferred-product criteria and the prescriber documents that preferred products are not appropriate.
- Applies to Natesto, Testosterone transdermal gel generics (Fortesta, Testim, Vogelxo) and testosterone transdermal solution generics.
Prescriber must provide written letter of medical necessity
For non-preferred topical testosterone, the prescriber must submit a written letter of medical necessity explaining why the preferred products (Androgel 1.62% and testosterone 1.62% generic) are not appropriate for the member.
- Prior authorization may be initiated by calling OptumRx at 1-866-525-5827.
Denial triggers: missing labs, age, or diagnosis
Requests may be denied if documentation does not include confirmatory evidence of low testosterone or required patient information.
- Missing two separate morning serum testosterone measurements <300 ng/dL (two labs on separate days) is a denial trigger.
- Missing documentation of member age (≥18) or diagnosis of primary or secondary hypogonadism may result in denial.
Clinical Thresholds and Definitions (Key Values)
Definitions
Step Therapy Requirements
| Step | Requirement |
|---|---|
| 1 | |
| Letter of medical necessity: prescriber must submit a written letter of medical necessity stating why preferred products (Androgel 1.62% and testosterone 1.62% generic) are not appropriate before coverage of non-preferred topical testosterone. |
Quantity Limits
Background
Topical testosterone formulations are indicated in this policy for treatment of male hypogonadism. Coverage for these agents is contingent upon biochemical confirmation of low serum testosterone — defined as < 300 ng/dL — documented by two morning laboratory measurements on separate days, and the patient meeting the minimum age requirement of 18 years.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.