Testosterone undecanoate injection (Aveed®)
OFFICE ADMINISTRATION [MEDICAL BENEFIT]
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 testosterone for IM injection and topical testosterone, AND
- Limited to a 30 day supply per fill
- Contraindicated in men with carcinomas of the breast or prostate, or known hyersensitivity to Aveed or any of its ingredients
- Warnings include serious pulmonary oil microembolism (POME) reactions and anaphylaxis
- The recommended dose of Aveed is 3 mL (750 mg) injected intramuscularly, followed by 3 mL (750 mg) injected after 4 weeks, then 3 mL (750 mg) injected every 10 weeks thereafter.
- 1 year
Last review date: December 2, 2019