Does Oscar Cover TRT? What PG122 and Two 2026 Drug Lists Require
TRT Provider Guide · Last verified: (sources checked November 9, 2026; Oscar’s Testosterone Replacement Therapy guideline PG122, Version 7, lists a last revision date of November 2, 2026) · Editorial research
Last updated: .
TRT Provider Guide is an independent decision resource for testosterone replacement therapy care. We may earn a commission if you use the tracked links to Male Excel or Hone on this page. That does not change the Oscar guideline or drug lists quoted below. Official Oscar links are not affiliate links.
The short answer
Oscar can cover testosterone replacement therapy (TRT) when the product is on your plan’s list, or approved as an exception, and you meet Oscar’s clinical criteria. The rulebook we opened is pharmacy guideline PG122, Version 7, “Testosterone Replacement Therapy,” last reviewed or revised on November 2, 2026 (original date June 23, 2022).
For hormone replacement in males with primary or hypogonadotropic hypogonadism, PG122 says testosterone products are medically necessary when all of these are met: a documented diagnosis of primary or secondary hypogonadism; the medication is prescribed by a qualified healthcare professional (the guideline’s examples include primary-care physicians, nurse practitioners, and physician assistants, and it asks for an endocrinologist or urologist when specialized expertise is needed); documented signs or symptoms of low testosterone; and clinical-chart documentation of one of four lab or diagnosis pathways, including two morning total testosterone concentrations below 300 ng/dL before treatment. If those prior-authorization criteria are met, the guideline says the requested medication will be approved for up to 36 months, with a note that state mandates may apply.
That 36-month approval window is a different design from many testosterone policies that authorize a year at a time. It is still a coverage decision, not a price, and it does not automatically pay for labs or visits.
The two official 2026 Oscar 4-tier formularies we opened — the standard-plans 4-tier list and the Florida 2026 4-tier list, both posted on Oscar’s 2026 forms pages — list generic testosterone cypionate 100 mg/ml or 200 mg/ml, testosterone enanthate 200 mg/ml, depo-testosterone 200 mg/ml, and selected testosterone gel presentations with prior authorization. On the standard 4-tier list those products (except methyltestosterone) are Tier 1 with PA. On the Florida list they are Tier 1B with PA. Jatenzo, Kyzatrex, Tlando, Xyosted, Androderm, AndroGel, Natesto, Aveed, and Testopel did not appear by name on either list we opened. PG122’s product table includes both formulary and non-formulary items and says members must be unable to use, or have tried and failed, preferred products first. Non-formulary requests go to a separate Non-Formulary Products Criteria policy, PG069.
If your Oscar plan will not cover the product you were prescribed, or you want a cash-pay online route instead of waiting on a determination, start with TRT Provider Guide's Find My TRT Path tool or compare a published cash-pay program such as Male Excel first, then Hone. Those links do not make Oscar cover the visit or the medication.
What does Oscar guideline PG122 require?
PG122 is an Oscar clinical guideline used for utilization-management decisions. The disclaimer says coverage is still subject to your policy, state and federal law, and, for Medicare Advantage, any in-force CMS national or local coverage determination.
The hypogonadism pathway is more than a lab number. It also requires signs or symptoms — the guideline’s examples include low sex drive, weak muscles or bones, or low energy — and a documented diagnosis. The diagnosis examples are broader than some other payer policies: they include not only orchiectomy, Klinefelter syndrome, chemotherapy, and pituitary injury, but also secondary causes such as opioid agonists, glucocorticoid treatment, chronic illness (including AIDS, chronic lung disease, and chronic kidney disease), diabetes mellitus, anorexia nervosa, and hyperprolactinemia. Those are examples in the guideline, not a do-it-yourself diagnosis.
The prescriber rule is also specific. A “qualified healthcare professional” can be a primary-care physician, nurse practitioner, or physician assistant. If the situation needs specialized expertise — accurate diagnosis, risk-benefit assessment, preparation and administration of a particular product, monitoring, or care coordination — the prescription should be provided by, or in consultation with, a specialist such as an endocrinologist or urologist.
If the hypogonadism prior-authorization criteria are met, approval is written as up to 36 months. State mandates may change that. The guideline marks that point with an “[s]” note.
PG122 also has separate, narrower pathways that this page does not treat as the default TRT answer:
- Delayed puberty in males, prescribed by a qualified specialist such as a pediatric endocrinologist, with bone-maturation assessment, approved for up to 12 months.
- Hypogonadism associated with HIV infection, approved for up to 36 months when the stated criteria are met.
- Palliative treatment of inoperable, hormone-responsive breast cancer in women, limited to testosterone cypionate, testosterone enanthate, or methyltestosterone, with oncology involvement, approved for up to a lifetime when the stated criteria are met.
- Hormone therapy for gender-affirming care, with a note that state regulatory guidelines and age restrictions may apply, approved for up to a lifetime when the stated criterion is met.
Uses the guideline calls experimental, investigational, or unproven include late-onset hypogonadism without a clinical diagnosis of hypogonadism; nonmedical use for lean muscle or athletic performance; erectile dysfunction in men with normal serum testosterone; and treatment of depression, fatigue, cognitive decline, or cardiovascular disease in men without documented hypogonadism. Appendix A expands those examples.
PG122 also discusses product-specific safety issues, including blood-pressure risk for oral testosterone undecanoate (Jatenzo, Tlando, Kyzatrex), pulmonary oil microembolism risk and a REMS program with at least 30 minutes of post-injection monitoring for Aveed, and transfer / virilization risk for topical gels. Product labels change. Review the current label for the exact drug with a clinician. See also TRT and blood pressure and FDA-approved testosterone products.
What do Oscar’s 2026 4-tier drug lists actually include?
We opened two official 2026 lists posted on Oscar’s forms pages: “List of the Drugs on our Formulary (Standard Plans - 4 Tier formulary)” and “List of the Drugs on our Formulary (Standard Plans - 4 Tier formulary) - FL 2026.” Both are labeled Oscar 2026 Formulary, List of Covered Drugs. The Florida file uses a 1A / 1B / 3-style tier display. The standard-plans file uses Tier 1 and Tier 3 in the androgen section we read. Those labels are not interchangeable.
Oscar will generally cover a listed drug when it is medically necessary, filled at an in-network pharmacy, and other plan rules are followed. Prior authorization, quantity limits, and step therapy may still apply. The lists also say that physician-administered drugs billed under the medical benefit are not handled as pharmacy-benefit formulary rows and require their own prior authorization.
A gel row on these Oscar lists is a real difference from several other marketplace lists we have reviewed, which did not print a testosterone gel at all. It still carries a PA flag. PG122’s Table 1 note also requires that members be unable to use, or have tried and failed, preferred products first.
If your plan uses a different Oscar formulary — including a New York individual list or another plan design posted on the forms pages — do not assume these two 4-tier files apply. Oscar also points members to an online drug look-up at hioscar.com/care-options and tells members to contact Concierge if a drug is not in the printed list. In-network providers can use the provider portal or call (855) 672-2755 about authorization.
How much will TRT cost with Oscar?
There is no honest national Oscar copay. The same generic injection is Tier 1 on one 2026 list and Tier 1B on the Florida list, and both still require prior authorization. Your deductible, copay or coinsurance, network pharmacy, and whether the drug is billed under the pharmacy or medical benefit all change the total. A 36-month authorization, if you get one, still does not freeze your cost-sharing.
Ask Oscar for a plan-specific estimate for the exact product and pharmacy, then add visits and labs. For cash-pay ranges, see TRT cost.
Can you use Oscar with an online TRT clinic?
A telehealth visit is not automatically an in-network Oscar claim, and a compounded cream or troche is not the same as the FDA-approved products on these lists. Many online TRT programs are cash-pay and will not submit an Oscar pharmacy claim.
If you want a provider that bills insurance, start with TRT providers that take insurance and confirm your exact Oscar network. If you want a defined cash-pay online program instead, Male Excel is first and Hone is second. Compare published prices on our Male Excel cost page. Use Find My TRT Path if the path is unclear.
See Male Excel’s published cash-pay program
How do I check my own Oscar testosterone coverage?
- Confirm your state and plan type, then open the matching 2026 formulary from your documents or Oscar’s 2026 forms pages.
- Search the exact product, strength, and form. Use the drug look-up if the printed list is unclear.
- Write down the tier and any PA, step-therapy, or quantity-limit flag.
- Read PG122 for the pathway that actually matches your situation — hypogonadism, already-on-treatment monitoring, delayed puberty, or another listed indication. Do not skip the signs-and-symptoms requirement.
- Ask your prescriber who will submit the prior authorization, which morning lab reports they will attach, and whether a preferred product has already been tried if the request is for a non-preferred or non-formulary item.
- Request a cost estimate and add visit and lab bills.
If Oscar denies the request, use the appeal steps in testosterone prior authorization. A cash-pay option can run in parallel; it does not replace an appeal.
What should you settle with your doctor first?
Coverage rules are not a diagnosis. FDA-approved testosterone products carry product-specific safety warnings. Testosterone can lower sperm production, and that effect may not fully reverse. If you want children, say so before anyone sends a prior-authorization request.
This page does not tell you to start, stop, or change testosterone, and it does not interpret your labs. See FDA-approved testosterone products, TRT and blood pressure, and TRT and fertility.
How we built this page
We opened Oscar Clinical Guideline PG122, Version 7, “Testosterone Replacement Therapy,” including the November 2, 2026 revision date, from hioscar.com/pharmacy/pg122v7; the 2026 standard-plans 4-tier formulary and the Florida 2026 4-tier formulary posted on Oscar’s 2026 forms pages; and Oscar’s pharmacy-guidelines and member look-up pages. We compared those primary documents so this URL would add Oscar-specific approval-duration, lab-pathway, and formulary evidence that the site’s generic insurance pages do not already serve.
What we could not confirm from the public materials used here: a complete 2026 6-tier “all other plans” formulary (a neighboring file on the forms page is a condition-specific chronic-care list, and we did not treat it as the 6-tier drug list); whether a later 2026 update changed a row after we opened these files; and how a given state’s mandate changes the 36-month approval window.
What we did not do: examine anyone, read anyone’s labs, submit an Oscar claim, or enroll with a provider. A clinician has not reviewed this page.
Oscar and TRT: frequently asked questions
Does Oscar cover TRT?
It can, when the product is covered and PG122’s applicable criteria are met. The hypogonadism pathway can be approved for up to 36 months. That is still subject to your plan, state rules, and cost-sharing.
Does Oscar cover testosterone injections?
Yes, on both 2026 4-tier lists we opened, generic testosterone cypionate and enanthate — and depo-testosterone 200 mg/ml — appear with prior authorization, at Tier 1 on the standard-plans list and Tier 1B on the Florida list.
Does Oscar cover testosterone gel?
Selected presentations (10 mg/act and 25 mg/2.5 g) appear on both of those lists, also with prior authorization, at the same tier as the generic injections on each list. Brand AndroGel did not appear by name.
Does Oscar cover Kyzatrex or Jatenzo?
Those brands are discussed in PG122, including in the product table and in the guideline’s blood-pressure discussion, but they did not appear by name on the two 4-tier lists we opened. A non-formulary request would follow PG069 and the preferred-product rule in Table 1.
Who can prescribe TRT for an Oscar prior authorization?
PG122 says a qualified healthcare professional, and it names primary-care physicians, nurse practitioners, and physician assistants as examples. It also says a specialist such as an endocrinologist or urologist should be involved when the situation needs that expertise.
Will Male Excel or Hone bill Oscar for me?
Do not expect a cash-pay online program to submit your Oscar pharmacy claim, and do not expect compounded medication to appear as an FDA-approved row on these lists.
Sources
- Oscar. Clinical Guideline: Testosterone Replacement Therapy (PG122, Ver. 7), original date June 23, 2022; reviewed/revised through November 2, 2026. hioscar.com/pharmacy/pg122v7
- Oscar. 2026 Formulary, List of Covered Drugs, standard-plans 4-tier list, posted as “List of the Drugs on our Formulary (Standard Plans - 4 Tier formulary).” PDF
- Oscar. 2026 Formulary, List of Covered Drugs, Florida 2026 4-tier list, posted as “List of the Drugs on our Formulary (Standard Plans - 4 Tier formulary) - FL 2026.” PDF
- Oscar. Clinical guidelines, pharmacy. hioscar.com/for-providers/clinical-guidelines/pharmacy
- Oscar. 2026 forms and notices, including formulary postings. hioscar.com/forms/2026
- Oscar. Drug look-up / care options, as cited in the 2026 formularies. hioscar.com/care-options