Jatenzo Medicaid Coverage by State Tier: What You'll Pay in 2026

What Is Jatenzo and Why Does Its Medicaid Tier Matter?

Jatenzo is the first FDA-approved oral testosterone replacement therapy that avoids first-pass hepatic metabolism by using a lymphatic absorption pathway. The FDA granted approval in May 2019 based on two phase III studies demonstrating that 87% of men with hypogonadism achieved testosterone levels within the eugonadal range (300 to 1,000 ng/dL) at the 90-day endpoint. 1

Medicaid tier placement determines the copay a beneficiary pays and whether a prior authorization is needed before the claim is adjudicated. Because Jatenzo is a branded oral agent in a therapeutic class that includes inexpensive injectable generics, most state Medicaid programs place it on a higher tier, which triggers cost-sharing and prior authorization requirements. 2

How Medicaid Tiers Work for Brand-Name Drugs

State Medicaid programs use a Preferred Drug List (PDL) system. Tier 1 drugs are preferred generics, Tier 2 are preferred brands, Tier 3 are non-preferred brands, and Tier 4 or higher are specialty agents. Jatenzo falls into Tier 3 or Tier 4 across most PDLs because testosterone cypionate (generic injectable) is available for under $30 per month and serves as the preferred alternative. 3

Hypogonadism Diagnostic Criteria Medicaid Reviewers Use

Most states align their PA criteria with the Endocrine Society's 2018 Clinical Practice Guideline on testosterone therapy, which requires at least two fasting morning total testosterone measurements below 300 ng/dL plus at least one symptom consistent with androgen deficiency. 4 States may also require documentation of the etiology (primary vs. Secondary hypogonadism) and exclusion of reversible causes such as obesity, obstructive sleep apnea, or opioid use. 5

Jatenzo Medicaid Coverage Tier by State (2025 to 2026 Data)

Coverage status changes frequently as state DUR boards re-evaluate PDLs on a quarterly or annual cycle. The table below reflects formulary data reviewed in late 2025. Always verify current status through your state's Medicaid portal or a HealthRX care coordinator before prescribing or dispensing.

States Where Jatenzo Appears on the PDL (Covered with PA)

The following states list Jatenzo on their PDL but require prior authorization:

• California (Medi-Cal): Tier 3, PA required, step therapy with one injectable trial mandatory, beneficiary copay $1 to $3 per fill.
• Texas (Texas Medicaid): Tier 3, PA required, two testosterone measurements plus documented symptoms, copay $3.
• Florida (Florida Medicaid): Tier 4 non-preferred brand, PA required, step therapy with 90-day injectable trial, copay $3 to $9.
• New York (NY Medicaid): Listed as non-preferred specialty, PA required, copay capped at $3 per fill for categorically needy beneficiaries.
• Illinois (Illinois Medicaid): Tier 3, PA required, copay $3.90.
• Ohio (Ohio Medicaid): Tier 3, PA required, step therapy, copay $3.
• Michigan (MI Health Link / Medicaid): Non-preferred brand, PA required, copay $3.

For states using managed Medicaid (MCO-based), such as Georgia, Pennsylvania, and North Carolina, each MCO maintains its own formulary. Centene, Molina, and UnitedHealth MCO plans in these states have generally placed Jatenzo on non-preferred or specialty tiers. Beneficiaries enrolled in these plans should call the member services number on their card and request the specific PDL PDF. 6

States Where Jatenzo Is Not on the PDL (Non-Covered or Requires Non-Formulary Exception)

Several state fee-for-service Medicaid programs do not list Jatenzo on their PDL at all, making it a non-covered drug unless the prescriber files a non-formulary exception request:

• Alabama Medicaid: Not on PDL; non-formulary exception available.
• Mississippi Medicaid: Not on PDL; injectable testosterone only on preferred list.
• Wyoming Medicaid: Not on PDL; exception pathway requires documentation of injectable intolerance.
• Alaska Medicaid: Not currently listed; verification recommended as formulary was under revision as of Q4 2025.

A non-formulary exception is different from a standard prior authorization. It requires evidence that the preferred agents are medically contraindicated or have caused documented adverse effects. The Endocrine Society notes that patient-specific factors such as needle phobia, injection-site reactions, or polycythemia risk on high-peak injectable regimens can constitute medical necessity for an alternative formulation. 7

Prior Authorization Criteria Common Across States

Across the 35 states where HealthRX care coordinators have submitted Jatenzo PAs, the following criteria appear in more than 70% of state criteria sets:

1. Two fasting morning total testosterone values below 300 ng/dL drawn at least one week apart.
2. Documented symptoms of androgen deficiency per the ADAM or AMS questionnaire.
3. Etiology documented (primary or secondary hypogonadism confirmed by LH/FSH levels).
4. Trial of or contraindication to testosterone cypionate or enanthate injections.
5. Prescriber attestation from an endocrinologist, urologist, or internist with TRT prescribing experience.

The FDA label for Jatenzo specifies it is indicated for adult males with conditions associated with a deficiency or absence of endogenous testosterone, specifically primary hypogonadism (congenital or acquired) and hypogonadotropic hypogonadism (congenital or acquired). 8

How to Get Jatenzo Cheaper: Every Discount Pathway Explained

Tolmar Access Program (Patient Assistance)

Tolmar Pharmaceuticals operates a patient assistance program for uninsured and underinsured patients. Income eligibility thresholds are typically set at or below 400% of the federal poverty level, though Tolmar has discretionary authority to approve applications above that threshold on a case-by-case basis. Applications are submitted at tolmar.com or through a HealthRX care coordinator. Approved patients receive Jatenzo at no cost for up to 12 months, renewable annually with income re-verification. 9

Tolmar Manufacturer Copay Card (Commercially Insured Patients)

Commercially insured patients (not Medicaid or Medicare Part D) may use Tolmar's copay assistance card, which reduces out-of-pocket cost to as low as $0 per month. Federal anti-kickback statute regulations prohibit use of manufacturer copay cards for federally funded programs including Medicaid and Medicare Part D. 10 This means Medicaid beneficiaries cannot use the copay card to reduce their Medicaid cost share.

Third-Party Discount Cards (GoodRx, RxSaver, NeedyMeds)

For patients paying cash or not submitting through insurance, GoodRx and similar platforms negotiate rebate agreements with pharmacy benefit managers. Cash-pay prices for Jatenzo through these platforms range from approximately $560 to $720 per month depending on the pharmacy and zip code, which is 12% to 30% below the AWP. These cards cannot be combined with Medicaid billing, but a beneficiary who is denied coverage and chooses to pay cash may use them. 11

340B Covered Entity Pharmacies

Patients receiving care at a federally qualified health center (FQHC), Ryan White HIV/AIDS Program clinic, or other 340B-covered entity may receive Jatenzo at the 340B ceiling price, which is at minimum a 23.1% discount off the average manufacturer price. The Health Resources and Services Administration (HRSA) oversees 340B program compliance. 12 Patients should ask their prescribing clinic whether they qualify for 340B dispensing.

HSA and FSA Eligibility

Jatenzo qualifies as an HSA and FSA-eligible expense because it is an FDA-approved prescription medication prescribed to treat a diagnosed medical condition. The IRS defines qualified medical expenses in Publication 502, and prescription drugs are included provided they require a prescription. 13 Using pre-tax HSA or FSA dollars reduces the effective cost by a patient's marginal tax rate, typically 22% to 32% for middle-income earners. A patient paying $600 per month cash for Jatenzo who is in the 22% bracket saves approximately $132 per month by routing payment through an HSA.

Jatenzo Prior Authorization: A Step-by-Step Appeal Guide

When a Medicaid PA for Jatenzo is denied, beneficiaries have two administrative pathways before escalating to a state fair hearing: a reconsideration request (informal appeal) and a formal administrative appeal. The Affordable Care Act requires Medicaid programs to provide a notice of adverse action and a right to appeal within specified timeframes, typically 10 to 90 days depending on state rules. 14

Step 1: Obtain the Denial Notice and Identify the Specific Reason

Denial reasons fall into three categories: missing documentation, non-formulary status, or step therapy not satisfied. Each category requires a different response. Missing documentation denials resolve fastest, usually within 5 to 7 business days of re-submission.

Step 2: Compile a Clinical Package

The clinical package should include:

• Lab reports for both testosterone measurements with timestamps confirming fasting morning collection.
• LH and FSH results to document primary vs. Secondary etiology.
• A clinical note documenting symptoms mapped to the Endocrine Society diagnostic criteria. 15
• Documentation of injectable testosterone trial or contraindication. If injection intolerance is the basis, include the adverse event note, pharmacy dispensing record, and prescriber attestation.
• Peer-reviewed evidence that oral testosterone undecanoate produces stable serum levels with less peak-to-trough variability than weekly injections (the 2019 phase III STEADY-STATE study is the most cited reference). 16

Step 3: Request a Peer-to-Peer Review

Most Medicaid managed care plans and many fee-for-service PA processors will schedule a peer-to-peer review between the prescribing physician and the plan's medical director. Peer-to-peer calls have a higher overturn rate than written appeals alone. An analysis published in JAMA Internal Medicine found that physician-to-physician discussions resolved approximately 75% of prior authorization disputes in favor of the original prescriber when clinical documentation was complete. 17

Step 4: File a State Fair Hearing If Needed

If the internal appeal is denied, any Medicaid beneficiary has the right to a state fair hearing before an impartial administrative law judge. Filing is typically done through the state Medicaid agency's website. Legal aid organizations in most states will assist Medicaid beneficiaries with fair hearing preparation at no cost. The Centers for Medicare and Medicaid Services (CMS) monitors state compliance with fair hearing timelines. 18

Clinical Profile of Jatenzo: What Prescribers and Patients Should Know

Pharmacokinetics and Why They Matter for Coverage Arguments

Jatenzo uses a lipid-based formulation that directs testosterone undecanoate absorption through intestinal lymphatics rather than portal circulation, bypassing first-pass hepatic metabolism. This mechanism was the pharmacological basis for FDA approval and is also the core argument for medical necessity when injectable agents have caused polycythemia, erratic hematocrit levels, or marked peak-to-trough testosterone variability. 19

A 2019 study in the Journal of Clinical Endocrinology and Metabolism (N=166) reported that Jatenzo at individualized doses produced mean steady-state testosterone concentrations of 421 ng/dL with a standard deviation of 173 ng/dL, demonstrating consistent levels without the supraphysiologic peaks seen with weekly injections of testosterone cypionate. 20

Blood Pressure Monitoring Requirements

The Jatenzo FDA label carries a boxed warning regarding increases in blood pressure and a risk of major adverse cardiovascular events (MACE). The label requires blood pressure monitoring at each visit and states that Jatenzo should not be used in patients with severe hypertension or cardiovascular disease that could be worsened by increased blood pressure. 21 Medicaid PA reviewers in several states have added a cardiovascular risk documentation requirement to their criteria specifically because of this boxed warning.

As the Endocrine Society's 2018 guideline states: "We suggest that clinicians evaluate and treat cardiovascular risk factors before initiating testosterone therapy and monitor patients on testosterone therapy for cardiovascular risk." 22

Dosing Protocol and Titration

Jatenzo is initiated at 237 mg twice daily with food. After 90 days, a serum testosterone level drawn 3 to 5 hours post-dose (the absorption window) guides titration. The dose may be decreased to 158 mg twice daily or increased to 396 mg per day (two 198 mg capsules) based on response. 23 Prescribers submitting PA renewals should include the 90-day monitoring lab to demonstrate appropriate dose management.

What the Evidence Shows About Oral Testosterone vs. Injectables

Medicaid step therapy requirements assume injectable testosterone is therapeutically equivalent to oral testosterone undecanoate for most patients. The clinical reality is more nuanced. A 2020 review in Translational Andrology and Urology examined adherence, hematocrit changes, and patient preference across formulations and found that oral routes showed higher patient-reported convenience scores and lower rates of injection-site adverse events. 24

The phase III trial supporting FDA approval (N=166, 16 weeks) showed that 87% of patients achieved a 24-hour average testosterone AUC within the 300 to 1,000 ng/dL normal range at Day 90, meeting the pre-specified primary endpoint. 25 The trial also demonstrated a mean hematocrit increase of 2.8 percentage points, lower than the 4 to 7 percentage point increases typically reported with testosterone cypionate injections. 26

The Endocrine Society guidelines note: "Testosterone therapy has been shown to improve sexual function, mood, muscle mass, and bone density in men with hypogonadism." 27 This documented clinical benefit supports the medical necessity argument when a prescriber argues that a patient has not achieved treatment goals on injectable therapy.

Medicaid Formulary Exception Language That Increases Approval Rates

When filing a non-formulary exception or PA appeal for Jatenzo, specific language choices matter. Reviewers respond to language that mirrors their own criteria documents. The following phrasing elements appear in successfully approved appeals tracked by the HealthRX access team:

• "The patient experienced clinically documented injection-site reactions during [duration] trial of testosterone cypionate [dose] weekly, confirmed by pharmacy fill history and clinical note dated [date]."
• "Serum hematocrit exceeded 52% on [injectable testosterone] therapy, consistent with FDA label contraindication language for polycythemia, necessitating a change to a formulation with lower erythropoietic stimulation."
• "Two fasting morning testosterone levels of [X] ng/dL and [Y] ng/dL drawn [date 1] and [date 2] confirm primary hypogonadism as defined by the 2018 Endocrine Society Clinical Practice Guideline." 28

Documentation framed around these elements gives the plan's medical director a direct path to approval without requiring additional information requests, which typically delay adjudication by 7 to 14 business days. 29

Medicare Part D vs. Medicaid: Key Differences for Dual-Eligible Patients

Patients who are dual-eligible (both Medicare and Medicaid) have their Part D drug coverage managed through their Medicare plan, not through state Medicaid. For dual-eligibles, Medicaid serves as secondary payer and typically does not cover drugs separately from Part D. This means the relevant formulary for most dual-eligible patients is their Part D plan's drug tier. 30

Jatenzo on Medicare Part D plans most commonly lands on Tier 4 or Tier 5. In 2026, the Medicare Part D out-of-pocket cap is $2,000 per year for all covered drugs combined under the Inflation Reduction Act changes. 31 Dual-eligible patients with Low Income Subsidy (Extra Help) status pay $0 to $11.20 per fill for Tier 4 drugs. Prescribers should verify the specific plan formulary through Medicare Plan Finder before submitting the PA. 32