testosterone (all brands) — CareFirst (Caremark)

Initial criteria

• Patient has diagnosis of primary hypogonadism (congenital or acquired) OR hypogonadotropic hypogonadism (congenital or acquired).
• Drug is not being prescribed for age-related hypogonadism (late-onset hypogonadism).
• For testosterone use in delayed puberty: patient is a carefully selected male with clearly delayed puberty not secondary to a pathological disorder; puberty is expected to occur spontaneously at a relatively late date.
• For metastatic mammary cancer: patient is premenopausal with breast cancer who has benefited from oophorectomy AND is considered to have a hormone-responsive tumor; request is for intramuscular testosterone enanthate injection (generic Delatestryl).
• Safety and efficacy not established in males less than 18 years old unless indicated for delayed puberty.