FEP Testosterone–Injection & Implant Medical Review Request

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Enter Patient Information

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

* Required Field

Enter Provider Information

  • Provider ID OR NPI: *
  • Provider's Name: *
  • Physician's Specialty: *
  • Street Address: *
  • City: *
  • State: *
  • ZIP Code: *
  • Email Address:
  • Phone Number:
  • Enter a 10 digit phone number.
  • Fax Number:
  • Enter a 10 digit phone number.
  • 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.

If you experience issues submitting this form, please try again later.

Or, print the form and mail to:

Blue Cross and Blue Shield of Kansas City
Pharmacy Services
P.O. Box 412735
Kansas City, MO 64141-2735

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Revised 12/29/16

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