Testosterone Topical Gel — CareFirst (Caremark)

Delayed puberty in carefully selected males with clearly delayed puberty not secondary to a pathologic disorder

Initial criteria

The requested drug is being prescribed for testosterone replacement therapy in adult males for conditions associated with a deficiency or absence of endogenous testosterone (primary or hypogonadotropic hypogonadism)
The requested drug is NOT being prescribed for age-related (late-onset) hypogonadism
Patient meets FDA indication age requirements (e.g., males ≥18 years for most formulations; Azmiro ≥12 years)
If indicated for delayed puberty, must be carefully selected males with clearly delayed puberty that is not secondary to a pathological disorder; x-ray of hand and wrist to assess bone age should be performed every 6 months during therapy
If indicated for breast cancer, the patient is premenopausal, has benefited from oophorectomy, AND has a hormone-responsive tumor; the request must be for intramuscular testosterone enanthate injection (generic Delatestryl)

Continuation may be granted if the patient continues to meet initial indication criteria and demonstrates ongoing clinical benefit