Testosterone Replacement Therapies

This policy covers testosterone replacement therapies for male hypogonadism (primary or secondary) and related indications—such as HIV‑infected men with low testosterone, men on chronic corticosteroids, and post‑orchiectomy patients—and allows use in women only for metastatic breast cancer. Coverage requires documented persistently low pre‑treatment serum testosterone on at least two occasions plus more than two hypogonadal symptoms including at least one “more specific” symptom, dosing consistent with FDA labeling or recognized compendia (or two peer‑reviewed articles for supported off‑label use), excludes FDA‑contraindicated or unsupported uses, may be limited to a single testosterone product, and is subject to the member’s benefit plan and applicable state regulations.

"Therapies are covered when proven effective for the relevant diagnosis or procedure based on current peer-reviewed scientific literature."