Testosterone enanthate injection (Xyosted™)
SELF ADMINISTRATION - SUBCUTANEOUS INJECTION
Indications for Prior Authorization:
- Indicated for testosterone replacement in adult males for conditions associated with a deficiency or absence of endogenous testosterone (primary hypogonadism (congenital or acquired), and hypogonadotropic hypogonadism (congenital or acquired).
The following criteria must be met for coverage:
- Patient is 18 years of age or older, AND
- Diagnosis of hypogonadism confirmed by medical record documentation including lab documentation of morning serum testosterone concentrations below normal range, AND
- Patient has persistent signs and symptoms (e.g., depressed mood, decreased energy, progressive decrease in muscle mass, osteoporosis, loss of libido) of androgen deficiency (pre-treatment), AND
- Other reasons for androgen deficiency have been ruled out (e.g. adrenal insufficiency, hypopituitarism), AND
- Medical justification is provided why patient cannot use both topical testosterone (gel and patch), and testosterone for IM injection, AND
- Blood pressure is adequately controlled
- Limited to a 30 day supply per fill
- Contraindicated in men with carcinomas of the breast or prostate
- The starting dose of Xyosted is 75 mg, administered subcutaneously in the abdominal region once a week.
- 1 year
Last review date: May 19, 2020