FEP Testosterone–Injection & Implant Medical Review Request

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• Required *

• Enter Patient Information

• Drug Name: *
• Blue KC ID (Not SS#): *
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• Patient First Name: *
• Patient Middle Initial:
• Patient Last Name: *
• Date of Birth: *
• Patient Group ID: *
• ICD-10 Diagnosis Codes: *

  Diagnosis Codes must be 3-8 characters along with decimals

  Codes must be 3 - 8 characters and 2 decimals.
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• Has the patient been using samples? Yes No
• Dose and Directions: *

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• Enter Provider Information

• Provider ID OR NPI: *
• Provider's Name: *
• Physician's Specialty: *
• Street Address: *
• City: *
• State: *
• ZIP Code: *
• Email Address:
• Phone Number:
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• Fax Number:*
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• Contact First Name: *
• Contact Last Name: *
• Contact Email Address: *
• Contact Phone Number: *
• Contact Phone Ext:
• Contact Fax Number:*

• For requests for Aveed, has the prescriber been certified by the Aveed REMS program?

  • Yes
  • No *

• 1. Will the patient be using this medication in combination with any other form of testosterone?

  • Yes
  • No *

• 2. Please answer the following questions based on the patient’s diagnosis.

  • Inoperable metastatic breast cancer OR   
  • Inoperable metastatic mammary cancer
  1. If initiating testosterone therapy, has the patient received at least one prior therapy for treatment of this condition?
     
     • Yes
     • No *
  2. Will the patient be monitored for hypercalcemia every 6 months and advised to discontinue testosterone if found to be present?
     
     • Yes
     • No *
  3. Will the liver function tests and hematocrit level be monitored every 6 months?
     
     • Yes
     • No *
  • Delay in sexual development and/or puberty
  1. Will the patient’s bone age of the hand and wrist be assessed every 6 months as determined by radiographic evidence?
     
     • Yes
     • No *
  2. Will the liver function tests and hematocrit level be monitored every 6 months?
     
     • Yes
     • No *
  Deficiency of testosterone/hypogonadism (attach lab values)

  • 1. Choose a file or files to attach (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

       To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

       
       
       
       
       
       
       

  • • Has the patient been on testosterone therapy in any dosage form continuously for the last 4 months (excluding samples)?

      NO – this would be the INITIATION of Testosterone therapy, please answer the following questions:
      1. Has the patient had two morning total testosterone levels less than 300 ng/dL on different days?
         
         • Yes
         • No *
      2. What is the patient’s hematocrit level?
         %
      3. For patients >40 years of age: Does the patient have a baseline PSA level < 4 ng/ml?
         
         • Yes
         • No
         • N/A - patient had a prostatectomy *
      4. Does the patient have current diagnosis of prostate cancer and/or palpable prostate nodules?
         
         • Yes
         • No *
      5. Does the patient have a concurrent diagnosis of benign prostate hyperplasia (BPH)?
         
         • Yes
         • No *
         • * IF YES, will the symptoms associaed with BPH be monitored for worsening symptoms?
           

           • Yes
           • No *
      6. Has the prescribing physician assessed the patient for their cardiovascular risk for myocardial infarction (MI), angina, and stroke?
         
         • Yes
         • No *
      7. Does the patient have a diagnosis of sleep apnea?
         
         • Yes
         • No *
         • * IF YES, is the patient being treated for their sleep apnea?
           

           • Yes
           • No *
    • Yes - this would be the CONTINUATION of therapy, please answer the following questions:
      1. Does the patient have a total testosterone level 800 ng/dL or less?
         
         • Yes
         • No *
      2. If the patient has BPH, have the patient’s symptoms worsened?
         
         • Yes
         • No
         • N/A - patient does not have BPH *
      3. Has the prescribing physician re-assessed the patient for their cardiovascular risk for myocardial infarction (MI), angina, and stroke?
         
         • Yes
         • No *
      4. Will the following be monitored every 12 months:
         • Serum testosterone concentrations
           
           • Yes
           • No *
         • Hematocrit levels
           
           • Yes
           • No *
         • For patients >40 years of age: Prostate specific antigen (PSA)
           
           • Yes
           • No
           • N/A - patient had a prostatectomy *
  • Gender Dysphoria (GD)
    1. Is the patient undergoing a female to male transition?
       
       • Yes
       • No *
    2. Is this medication being prescribed by an endocrinologist?
       
       • Yes
       • No *
    3. Has the patient met the DSM-5 criteria for Gender Dysphoria?
       
       • Yes
       • No *

If you have any additional information pertinent to this patient’s therapy, please specify.

• Checking this box will send a copy of your form to the email address provided.