methyltestosterone — CareFirst (Caremark)
Breast cancer (hormone-responsive tumor)
Preferred products
- topical testosterone
- injectable testosterone
Initial criteria
- The requested drug is being prescribed for a premenopausal patient with breast cancer who has benefited from oophorectomy AND is considered to have a hormone-responsive tumor.
- The requested drug is NOT being prescribed for age-related hypogonadism (also referred to as late-onset hypogonadism).
- The patient meets ONE of the following: has experienced an inadequate treatment response to an alternative testosterone product (e.g., topical testosterone, injectable testosterone); has experienced an intolerance to an alternative testosterone product; or has a contraindication that would prohibit a trial of alternative testosterone products.
Reauthorization criteria
- All patients requesting authorization for continuation of therapy must meet all requirements in the coverage criteria section.
Approval duration
36 months