Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypogonadism. 
Treatment: Formulary exception for Testosterone Gel 1%. 

The insurer denied: Formulary exception for Testosterone Gel 1%. 
The denial is upheld. 

This is an adult male with hypogonadism. Request for continuation of Testosterone Gel 1% is under review. The prior request was denied because "The Plan received a formulary exception request from your prescriber for coverage of Testosterone 1% gel for use in the treatment of other specified abnormal findings of blood chemistry. This is the final adverse determination for this formulary exception request. The request was denied because: Coverage for this medication is denied for the following reason(s). We reviewed the information we received about your condition and circumstances. We used the plan approved policy when making this decision. The policy states that this medication may be approved when: 
- The member has a clinical condition or needs a specific dosage form for which there is no alternative on the formulary OR -The listed formulary alternatives are not recommended based on published guidelines or clinical literature OR - The formulary alternatives will likely be ineffective or less effective for the member OR - The formulary alternatives will likely cause an adverse effect OR - The member is unable to take the required number of formulary alternatives for the given diagnosis due to a trial and inadequate treatment response or contraindication OR - The member has tried and failed the required number of formulary alternatives. Based on the policy and the information we have, your request is denied. We did not receive any documentation that you meet any of the criteria outlined above. Formulary alternative(s) are testosterone transdermal gel 25 mg/2.5 g (1%); testosterone transdermal gel 10 mg/act (2%); testosterone cypionate; testosterone enanthate. Requirement: 3 in a class with 3 or more alternatives, 2 in a class with 2 alternatives, or 1 in a class with only 1 alternative. Please refer to your plan documents for a complete list of alternatives."  The provider is appealing this determination. He has tried and failed testosterone 25milligram/2.5gram a few years ago. 

The health plan should not cover the requested testosterone gel 1%. 

This request is for continuation of testosterone gel 1%. The formulary alternatives are transdermal gel 25 milligram/2.5 gram (1%); testosterone transdermal gel 10 milligram /act (actuation transdermal) (2%); testosterone cypionate; testosterone enanthate. The patient has tried and failed transdermal gel 25 milligram /2.5 gram (1%). The patient does not have a documented trial with or contraindication to testosterone transdermal gel 10 milligram /act (actuation transdermal) (2%). The patient does not have a documented medical reason for using testosterone gel 1% over testosterone transdermal gel 10 mg/act (actuation transdermal) (2%). The Endocrine Society guidelines on male hypogonadism do not recommend the use of testosterone gel 1% over transdermal gel 10 milligram /act (actuation transdermal) (2%). Testosterone cypionate and testosterone enanthate are also acceptable alternatives, although require injection and may result in more variable testosterone levels than testosterone gel formulations.