Under some plans, including plans that use an open or closed formulary  Android, Anadrol, Methitest, methyltesterone, Oxandrin, oxandrolone, Testred and Winstrol are subject to precertification.  If precertification requirements apply Aetna considers Androderm, Androgel, Android, Anadrol, Androxy, Delatestryl, Depo-Testosterone, First Testosterone, Methitest, methyltesterone, Oxandrin, oxandrolone, Striant, Testim, testosterone cypionate, testosterone enanthate, Testred, and Winstrol to be medically necessary for those members who meet the following precertification criteria:

For Anadrol, Oxandrin, oxandrolone and Winstrol

Documented diagnosis of wasting syndrome (weight loss/cachexia) due to HIV-AIDS, cancer or other major chronic progressive diseases.

  

For Android, Methitest, methyltesterone and Testred (for members greater than or equal to 65 years of  age)

Documentation that:

• Member has tried and failed alternative drugs that are appropriate in the elderly to the treat the condition OR
• Member has been stabilized on the drug for an extended period and discontinuation or change in the drug might result in physical and/or mental impairment OR
• Member is in a critical or terminal state and disruption of therapy at this point would be inappropriate AND
  Member is being monitored AND
  Member has no known history of emergency department visits and/or hospital admissions from use of the drug in the member
  
  

Under some plans, including plans that use an open or closed formulary, Striant and Testim are subject to step-therapy.  Aetna considers Striant and Testim to be medically necessary for those members who meet the following step-therapy criterion:

A documented trial of one month of Androderm or Androgel - alternatives on the Aetna Medicare Preferred Drug List

If it is medically necessary for a member to be treated initially with a medication subject to step-therapy, the member's treating physician may contact the Aetna Pharmacy Management Precertification Unit to request coverage as a medical exception at 1-800-414-2386. (See criteria under section III below.)

Anadrol, Android, Androxy, Androgel, Delatestryl, Depo-Testosterone,  Oxandrin, Striant, Testim, Testred and Winstrol are currently Not Covered Part D drugs under the Aetna Medicare Prescription Drug Plan.* Therefore, they are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Anadrol, Android, Androxy, Androgel, Delatestryl, Depo-Testosterone, Oxandrin, Striant, Testim, Testred and Winstrol to be medically necessary for those members who meet ANY of the following criteria:

For Android, Androxy, Androgel, Delatestryl, Depo-Testosterone and Testred

A.   A documented:

• Contraindication to one covered testosterone alternative indicated for the member's condition OR
• Intolerance to one covered  testosterone alternative indicated for the member's condition OR
• Allergy to one covered testosterone alternative indicated for the member's condition OR
• Failure of an adequate trial of one month of one covered testosterone alternative indicated for the member's condition.

For Striant and Testim

A.   A documented:

• Contraindication to one of the following covered alternatives: Androderm or Androgel OR
• Intolerance to one of the following covered alternatives: Androderm or Androgel OR
• Allergy to one of the following covered alternatives: Androderm or Androgel OR
• Failure of an adequate trial of one month of one of the following covered alternatives: Androderm or Androgel

For Anadrol, Oxandrin and Winstrol

A.   A documented:

• diagnosis of wasting syndrome (weight loss/cachexia) due to HIV-AIDS, cancer or other major chronic progressive diseases.

AND

B.   A documented (For Oxandrin ONLY):

• Contraindication to the covered generic equivalent indicated for the member's condition OR
• Intolerance to the covered generic equivalent indicated for the member's condition OR
• Allergy to the covered generic equivalent indicated for the member's condition OR
• Failure of an adequate trial of one month of the covered generic equivalent indicated for the member's condition.