Testosterone pellets (Testopel)
OFFICE ADMINISTRATION
Indications for Prior Authorization:
- Primary hypogonadism
- Testicular failure due to bilateral torsion, orchitis, vanishing testes syndrome, cryptorchidism, or orchidectomy
- Hypogonadotrophic hypogonadism
- LHRH deficiency, pituitary hypothalamic injury from tumors, trauma, or radiation
- Male delayed puberty
The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:
- Treatment of female patients with symptoms of menopause or decreased libido
- Palliation therapy in post-menopausal women with breast cancer
- Any other diagnosis not listed in the approved indications
- The drug is not approvable for use in men with breast or prostate cancer
All of the following must be met:
- Treatment failure with topical and intramuscular testosterone administration
- Failure is defined as the inability to achieve normal plasma testosterone levels
Dosing:
- Pellet SC implantation 150 mg to 450 mg every 3-6 months
Approval:
2 months
Last review date: July 10, 2018