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 every 3-6 months

Approval: 

2 months


 

Last review date: December 2, 2013

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