Testosterone Injection (e.g., Depo-Testosterone)

OFFICE ADMINISTRATION / SELF ADMINISTRATION

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, orchtis, vanishing testis syndrome; or orchidectomy
    • Hypogonadotropic hypogonadism (congenital or acquired)-gonadotropin or LHRH deficiency, or pituitary-hypothalamic injury from tumor, trauma, or radiation

Prior authorization criteria:

  • Diagnosis of hypogonadism confirmed by medical record documentation including lab documentation of morning serum testosterone concentrations below normal range, AND
  • Other reasons for androgen deficiency have been ruled out (e.g. adrenal insufficiency, hypopituitarism), AND
  • Limited to a 30 day supply per fill
  • Contraindicated in men with carcinomas of the breast or prostate

Dosing:

  • 50-400 mg administered every two to four weeks

Approval:

  • One year

 

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