Download Depo-Testosterone

PRIOR AUTHORIZATION CRITERIA
DRUG CLASS
TESTOSTERONE PRODUCTS - INJECTABLE
BRAND NAME
(generic)
DEPO-TESTOSTERONE
(testosterone cypionate injection)
Status: CVS Caremark Criteria
Type: Initial Prior Authorization
POLICY
COVERAGE CRITERIA
 Depo-Testosterone (testosterone cypionate injection) will be covered with prior authorization when the following
criteria are met:
o The drug is being prescribed for a male patient with congenital or acquired primary hypogonadism (i.e.,
testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, or
orchidectomy) OR
o The drug is being prescribed for a male patient with congenital or acquired hypogonadotropic
hypogonadism (i.e., gonadotropin or luteinizing hormone-releasing hormone [LHRH] deficiency, or
pituitary-hypothalamic injury from tumors, trauma, or radiation)
AND
o The patient has NOT received testosterone medication in the last 12 months AND
o The patient had or currently has at least TWO confirmed low testosterone levels according to current
practice guidelines or your standard lab reference values
OR
o The drug is being prescribed for a male patient with congenital or acquired primary hypogonadism (i.e.,
testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, or
orchidectomy) OR
o The drug is being prescribed for a male patient with congenital or acquired hypogonadotropic
hypogonadism (i.e., gonadotropin or luteinizing hormone-releasing hormone [LHRH] deficiency, or
pituitary-hypothalamic injury from tumors, trauma, or radiation)
AND
o The patient has received testosterone medication in the last 12 months AND
o The patient had or currently has at least ONE confirmed low testosterone level according to current
practice guidelines or your standard lab reference values
REFERENCES
1. Assurant Health Prior Authorization Approval Policy.
© 2016 Caremark. All rights reserved.
Testosterone - Depo-Testosterone Policy Assurant Health C6858-A 04-2016.doc
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