ModifiedMass General Brigham Health PlanPolicy N/A

Androderm patches

Defines pharmacy benefit step-therapy/prior-authorization placement for testosterone products effective 01/01/2026 for Commercial/Exchange members, specifying first-line and second-line medications and authorization criteria for Androderm patches and related products.

Policy Summary

PayerMass General Brigham Health Plan

PolicyAndroderm patches

Policy CodePolicy N/A

Change TypeModified (prior auth/step-therapy update)

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain authorization when prescribing second-line testosterone products unless the member has met step-therapy requirements or is a new-to-plan member currently receiving the medication within 90 days (excluding samples or patient assistance supply).

SourceLink

POLICY UPDATE CHANGES

Effective 01/01/2026 the testosterone products policy updated prior authorization language to mirror step therapy configuration and removed Xyosted, Jatenzo and Kyzatrex as these agents moved to nonformulary status.

Second-line agents will pay if the member has filled at least two different first-line medications or a second-line medication within the past 180 days.

Authorization may be granted for members new to the plan within the past 90 days who are currently receiving treatment with the requested medication, excluding samples or manufacturer's patient assistance program supply.

9First-Line Agents Listed

2Second-Line Agents Listed

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Summary of policy changes

This bulletin governs placement of testosterone products within the pharmacy benefit step-therapy program and defines which agents are covered without prior authorization versus those requiring step completion or prior authorization; it designates multiple first-line agents as covered and Androderm patches as second-line requiring step completion/PA. The policy has been updated periodically since 2017 and the changes described here become effective 01/01/2026.

Policy timing and thresholds

Effective Date2026-01-01

Last Review2025-10-08

Lookback (step-therapy)180 days

New-member grace period90 days

Material changes & revision notes

2026-01-01revisedLatest

Removed Xyosted, Jatenzo and Kyzatrex from the policy (moving to nonformulary) and updated prior authorization language to mirror step therapy configuration. (Removed specific agents from coverage and aligned PA language with step therapy program.)

clarified

Explicit 180-day lookback requirement for step-therapy fulfillment: second-line medications will pay if the member has filled at least two different first-line medications or a second-line medication within the past 180 days.

revised

90-day new-member allowance clarified: authorization may be granted for members new to the plan within the past 90 days who are currently receiving the requested medication, excluding samples or manufacturer's patient assistance program supply.

Effective 01/01/2026 the policy updated prior authorization language to mirror the step therapy program and removed Xyosted, Jatenzo, Kyzatrex from coverage (moved to nonformulary); the bulletin also clarifies an explicit 180-day lookback for step-therapy fulfillment and a 90-day new-member allowance for members currently receiving the requested medication.

Drug groups and formulary status

First-Line medications (covered without prior authorization)mixedCovered

	Testosterone enanthate injection
	Testosterone cypionate injection
	Testosterone topical gel 1% (compare to AndroGel or Testim)
	Testosterone topical gel pump 1% (compare to Vogelxo)
	Testosterone topical gel 2% (compare to Fortesta Gel)
	Testosterone topical solution 30 mg/act (compare to Axiron solution)
	Testosterone topical gel 1.62% (compare to AndroGel Pump 1.62%)
	Testosterone topical 1.62% (compare to AndroGel topical 1.62%)
	Tlando (testosterone undecanoate)

Second-Line medications (require step-therapy completion or PA per rules)mixed

	Androderm patch 2mg/24hr
	Androderm patch 4mg/24hr

Products recently removed from policy (nonformulary as of 01/01/2026)mixedNot Covered

	Xyosted
	Jatenzo
	Kyzatrex

Authorization and step-therapy criteria

Authorization Criteria for Second-Line Agents (including Androderm)

Authorization may be granted when ALL of the following are met:

ALL of the following

Member history requirement
- Member has had an inadequate response, adverse reaction or contraindication to two first-line agents
- Member has had an inadequate response, adverse reaction or contraindication to one second-line agent
Member may be granted authorization if new to the plan within the past 90 days and currently receiving the requested medication (excluding samples or manufacturer patient assistance program supply)90 days
Excludes samples or manufacturer patient assistance program supply

What prescribers and pharmacy staff must do

Prior Authorization

Prior authorization for second-line agents

Obtain authorization when prescribing second-line testosterone products (e.g., Androderm) unless the member has met step-therapy requirements or is a new-to-plan member currently receiving the medication within 90 days (excluding samples or patient assistance supply).

Effective 01/01/2026
Affected agent example: Androderm patch (2mg/24hr and 4mg/24hr)

Step Therapy

Step-therapy fulfillment

Ensure member has filled at least two different first-line medications or at least one second-line medication within the past 180 days before second-line products will pay.

180-day lookback: second-line will pay only if member filled ≥2 different first-line meds or ≥1 second-line med within the past 180 days

Background and references

The step-therapy program defines first-line medications that are covered without prior authorization and lists Androderm patches (2mg/24hr and 4mg/24hr) as second-line products that require completion of step-therapy or prior authorization; the policy notes multiple historical reviews and modifications since 2017 and the current configuration is effective 01/01/2026.

References: prescribing information for Androderm, AndroGel (1% and 1.62%), Axiron, Fortesta, Testim and other testosterone product prescribing information, and the Endocrine Society clinical practice guideline (Bhasin et al., 2010) are cited as sources informing the policy.

Document versioning

2025-10-08prior_review

Policy reviewed and updated at September P&T; decision made to remove Xyosted, Jatenzo and Kyzatrex and to update prior authorization language to mirror step therapy configuration (effective 01/01/2026).

2026-01-01effectiveLatest

Effective date for updated testosterone products policy: prior authorization language aligned with step therapy and Xyosted, Jatenzo and Kyzatrex moved to nonformulary; second-line agents require step-therapy fulfillment (180-day lookback) and new-member 90-day allowance applies.