Depo-Testosterone — Medical Mutual

Initial criteria

• The medication is being prescribed for the treatment of hypogonadism (primary or secondary) in a male patient, delayed puberty or induction of puberty in a male patient 14 to 18 years of age for testosterone cypionate or 14 to 25 years of age for testosterone enanthate.

Reauthorization criteria

• If Testopel request is for up to 6 pellets, approve.
• If Testopel request is for 7 to 12 pellets, approve if: Patient has BMI of >25; OR Patient has not responded to lower dose confirmed by a morning serum testosterone level that is not within the mid-normal range of 250-500 ng/dl 1 month after initiation of testosterone therapy.

Approval duration

6 months