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

OFFICE ADMINISTRATION / SELF ADMINISTRATION

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

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, 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 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
  • If age-related hypogonadism, patient has documented symptoms of sexual dysfunction including at least one of the following:
    • Disturbances in potency
    • Decreased morning erections
    • Reduced sexual libido and activity
  • 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

 

Last review date: February 18, 2020

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