DELATESTRYL (testosterone cypionate) 

OFFICE ADMINISTRATION / SELF ADMINISTRATION

Testosterone cypionate 200 mg/mL, 1 ML vial does not require prior authorization, but does have a quantity limit of 4 ML every 28 days.  Prior authorization is required for any request above 4 ML every 28 days.

Testosterone cypionate 100 mg/mL, 10 ML vial requires prior authorization including medical rationale for exceeding 4 ML quantity limit.

Indications for Prior Authorization:
  • Replacement therapy in males in conditions associated with symptoms of deficiency or absence of endogenous testosterone
    • Primary hypogonadism (congenital or acquired) - testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, age-related hypogonadism; or orchidectomy
    • Hypogonadotropic hypogonadism (congenital or acquired) - gonadotropin or LHRH deficiency, or pituitary-hypothalamic injury from tumor, trauma, or radiation
    • Hormone therapy for transgender males (female-to-male)
Prior authorization criteria:
  • Diagnosis of hypogonadism or hormone therapy for transgender males is confirmed by medical record documentation including lab documentation of morning serum testosterone concentrations; AND
  • For hypogonadism: Other reasons for androgen deficiency have been ruled out (e.g. adrenal insufficiency, hypopituitarism); AND
  • For age-related hypogonadism: patient has documented symptoms of sexual dysfunction including at least one of the following:
    • Reduced sexual libido and activity.
    • Decreased morning erection
    • Disturbances in potency
Dosing:
  • For replacement in the hypogonadal male, 50-400 mg should be administered every two to four weeks.
  • Quantity limit is a 30 day supply per fill.
Coverage Duration:
  • One year
Additional Information:
  • Testosterone cypionate is contraindicated in men with carcinomas of the breast or prostate

 

Last review date: March 24, 2022

Rite Aid Pharmacy Patients: All Rite Aid pharmacies nationwide are closing! Please be on the lookout for information from Rite Aid pharmacies about their bankruptcy and store closures. Call your Rite Aid pharmacy for questions about your prescriptions and new pharmacy options. WHA is here to help as well. Contact Us via Phone