testosterone cypionate injection — CareFirst (Caremark)

Initial criteria

• Diagnosis of primary hypogonadism (congenital or acquired) defined as testicular failure due to conditions such as cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome, orchiectomy, Klinefelter’s syndrome, chemotherapy, or toxic damage from alcohol or heavy metals
• OR diagnosis of hypogonadotropic hypogonadism (congenital or acquired) due to gonadotropin or luteinizing hormone-releasing hormone deficiency, pituitary-hypothalamic injury from tumors, trauma, or radiation
• Patient age ≥ 18 years (safety and efficacy in younger males not established)
• Testosterone therapy NOT prescribed for age-related hypogonadism (late-onset hypogonadism)
• For breast cancer use: patient is premenopausal with breast cancer who has benefited from oophorectomy AND is considered to have a hormone-responsive tumor AND the requested drug is intramuscular testosterone enanthate injection (generic Delatestryl)