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Blue Cross & Blue Shield of MississippiAll Plans · Prior Auth · Medical Policy · Endocrinology, PharmacyMedium impact

Testosterone Replacement Therapy

Effective date
Not stated in the notice
Identified
Jun 20, 2026

Summary

Injectable testosterone cypionate and testosterone enanthate do not require prior authorization, and prior authorization is only required for non-injectable testosterone formulations. For Androgel, Testim, or Testopel requests, testosterone replacement is medically necessary when the individual has a documented diagnosis of a pituitary tumor, Klinefelter's syndrome, Kallmann's syndrome, or bilateral orchiectomy, or a documented diagnosis of hypogonadism with signs and symptoms of low testosterone and two low total testosterone levels from morning samples collected between 8:00 a.m. and 10:00 a.m. on different days. Aveed, Axiron, Azmiro, Fortesta, Natesto, Vogelxo, Xyosted, and oral testosterone products are considered not medically necessary because other formulary options exist.

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What to do

Action · 9 steps
01Billing team: Do not request prior authorization for injectable testosterone cypionate or testosterone enanthate under this policy, and request prior authorization only for non-injectable testosterone formulations.
02For Androgel, Testim, or Testopel, the provider must submit documentation showing an appropriate trial of both injectable testosterone cypionate and injectable testosterone enanthate could not adequately raise total testosterone to within the normal laboratory reference range, with both morning levels collected between 8:00 a.m. and 10:00 a.m. The provider must also submit the testosterone levels the lab considers normal.
03The dose requested must be within the policy quantity limits, for example 1 (10 ml) vial per month for testosterone cypionate 100 mg/ml, 1 (5 ml) vial per month for testosterone enanthate 200 mg/ml, and 6 pellets every 3 months for Testopel.
04A medication trial is 3 months of treatment at appropriate doses, and BCBSMS determines the trial and adherence from pharmacy claims data for the preceding twelve months.
05Medical records that only list previously prescribed medications do not show a medication trial.
06Samples do not count as current or stable therapy.
07Services related to delivery or administration of a medication that were not approved through the BCBSMS prior authorization review will be considered not medically necessary.
08Testosterone replacement is considered not medically necessary if the only symptom is erectile dysfunction or impotence.
09BCBSMS makes no payment for services not documented to be medically necessary.

Codes mentioned

J1071J1073J3121J1072J3145C75.1D35.2E23.6E29.1F32.9M62.59Q98.0Q98.4R53.81R53.83R68.82

Original notice

Testosterone Replacement Therapy
bcbsms.com · Always check the source before changing claims.
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Related changes

See all Blue Cross & Blue Shield of Mississippi changes →
State and School Employees' Health Insurance Plan - Testosterone Replacement TherapyMediumNo effective date · Medical PolicyFree Testosterone TestingMediumNo effective date · Medical PolicyEstrogen Hormone Testing: Estradiol and EstroneMediumNo effective date · Medical PolicyLuteinizing Hormone (LH) TestingMediumNo effective date · Medical PolicyBrowse every Blue Cross & Blue Shield of Mississippi change in the policy list

Related policy hubs

Blue Cross & Blue Shield of Mississippi policiesEndocrinologyPharmacyCode J1071Code J1073Code J3121Code J1072Code J3145Code C75.1Code D35.2Code E23.6Code E29.1Code F32.9Code M62.59Code Q98.0Code Q98.4Code R53.81Code R53.83Code R68.82

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