XYOSTED (testosterone enanthate)

XYOSTED (testosterone enanthate)

SELF ADMINISTRATION - SUBCUTANEOUS INJECTION

Indications for Prior Authorization: 

• Indicated for testosterone replacement in adult males for conditions associated with a deficiency or absence of endogenous testosterone (primary hypogonadism (congenital or acquired), and hypogonadotropic hypogonadism (congenital or acquired).

The following criteria must be met for coverage:

• Patient is 18 years of age or older, AND
• Diagnosis of hypogonadism confirmed by medical record documentation including lab documentation of morning serum testosterone concentrations below normal range, AND
• Patient has persistent signs and symptoms (e.g., depressed mood, decreased energy, progressive decrease in muscle mass, osteoporosis, loss of libido) of androgen deficiency (pre-treatment), AND
• Other reasons for androgen deficiency have been ruled out (e.g. adrenal insufficiency, hypopituitarism), AND
• Medical justification is provided why patient cannot use both topical testosterone (gel and patch), and testosterone for IM injection, AND
• Blood pressure is adequately controlled
• Limited to a 30 day supply per fill
• Contraindicated in men with carcinomas of the breast or prostate

Dosing:

• The starting dose of Xyosted is 75 mg, administered subcutaneously in the abdominal region once a week.

Approval: 

• 1 year