Testim — CareFirst (Caremark)

Initial criteria

• Patient has diagnosis of primary hypogonadism (congenital or acquired) OR hypogonadotropic hypogonadism (congenital or acquired).
• Patient is male (adult unless otherwise specified).
• Requested drug is being used for replacement therapy for conditions associated with deficiency or absence of endogenous testosterone.
• Requested drug is NOT being prescribed for age-related hypogonadism (also referred to as late-onset hypogonadism).
• For breast cancer indication: patient is premenopausal with a hormone-responsive tumor AND has benefited from oophorectomy AND request is for intramuscular testosterone enanthate injection (generic Delatestryl).
• For delayed puberty indication: patient is a carefully selected male with clearly delayed puberty that is not secondary to a pathologic disorder, and conservative doses are justified if not responsive to psychological support.
• For gender dysphoria indication: use consistent with recognized compendial use for transgender or gender diverse persons.