FDA-approved, for example:

• Delayed puberty
• Hypogonadotropic hypogonadism
• Metastatic mammary cancer (females)
• Primary hypogonadism

Note: The above list may not include all FDA-approved indications.

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

• All PA requests must include clinical diagnosis, drug name, dose, and frequency.
• A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
• For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
• Additional criteria may apply, depending upon the member’s condition and requested medication (see below).

Androderm, Striant, Testopel, testosterone cypionate, testosterone enanthate, testosterone 1% gel packet and tube, testosterone 1.62% gel packet and pump, and testosterone 2% gel pump and solution for male members

• Documentation of all the following is required:
  • appropriate diagnosis; and
  • a low testosterone level with dates drawn and reference ranges (< 300 ng/dL total serum testosterone). 

Aveed

• Documentation of all the following is required:
  • appropriate diagnosis; and
  • a low testosterone level with dates drawn and reference ranges (< 300 ng/dL total serum testosterone); and
  • an inadequate response to 90 days of therapy or adverse reaction to all of the following:
    • testosterone enanthate intramuscular injection; and
    • testosterone cypionate intramuscular injection. 

Jatenzo

• Documentation of all the following is required:
  • appropriate diagnosis; and
  • a low testosterone level with dates drawn and reference ranges (< 300 ng/dL total serum testosterone); and
  • an inadequate response or adverse reaction to two non-injectable formulations of testosterone, or a contraindication to all non-injectable formulations of testosterone. 

testosterone enanthate for female members

• Documentation of the following is required:
  • diagnosis of metastatic mammary cancer. 

testosterone powder

• Documentation of all the following is required:
  • appropriate diagnosis; and
  • clinical rationale why other commercially available alternatives of the requested drug cannot be used; and
  • appropriate tests and labs. 

Xyosted

• Documentation of all the following is required:
  • appropriate diagnosis; and
  • a low testosterone level with dates drawn and reference ranges (< 300 ng/dL total serum testosterone); and
  • an inadequate response to 90 days of therapy or adverse reaction to all of the following:
    • testosterone enanthate intramuscular injection; and
    • testosterone cypionate intramuscular injection. 

Please note: The MassHealth agency does not pay for any drug when used for the treatment of male or female sexual dysfunction as described in 130 CMR 406.413(B): Drug Exclusions (see link below).

https://www.mass.gov/regulations/130-CMR-406000-pharmacy-services