Transcription of Testosterone Replacement or Supplementation Therapy
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Testosterone Replacement or Supplementation Therapy
UnitedHealthcare Commercial Medical Benefit Drug Policy Testosterone Replacement or Supplementation Therapy Policy Number: 2022D0076E. Effective Date: January 1, 2022 Instructions for Use Table of Contents Page Community Plan Policy Coverage Rationale .. 1 Testosterone Replacement or Supplementation Applicable Codes .. 3 Therapy 6. Benefit Considerations .. 6. Clinical Evidence .. 7. Food and Drug Administration .. 7. References .. 7. Policy History/Revision Information .. 8. Instructions for Use .. 8. Coverage Rationale See Benefit Considerations This policy refers to the following Testosterone products: Testosterone cypionate (Depo- Testosterone ). Testosterone enanthate Testosterone pellets (Testopel ). Testosterone undecanoate (Aveed ). Injectable Testosterone and Testopel ( Testosterone pellets) are proven for Replacement Therapy in conditions associated with a deficiency or absence of endogenous Testosterone , including primary hypogonadism (congenital or acquired) and hypogonadotropic hypogonadism (congenital or acquired).
Aromatase inhibitor (e.g., Arimidex [anastrozole], Femara [letrozole], Aromasin [exemestane]) and . o Dosing is in accordance with the United States Food and Drug Administration approved labeling; and o Initial authorization will be for no more than 12 months.
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