An Aviation Medical Examiner can issue your certificate at the exam if your records meet every Federal Aviation Administration (FAA) requirement. At Longevity Benchmark, we track the clinical standards that determine whether pilots receive same-day clearance. The program is called Conditions AMEs Can Issue (CACI). Your examiner decides from the records you bring, so they have to be exact and current. Proper preparation prevents unnecessary grounding delays.
The Verdict
How CACI Low Testosterone Enables Same-Day Issuance
An Aviation Medical Examiner can issue a testosterone FAA medical certificate at the exam without sending the file to the FAA first. This expedited path falls under the Conditions AMEs Can Issue framework. Under CACI, the examiner signs it when the applicant meets every criterion on that condition's worksheet.
A condition must meet every published standard. The agency publishes a dedicated CACI, Low Testosterone (Low T) Hypogonadism Worksheet, updated 04/29/2026. When an applicant satisfies every item, the examiner signs the medical certificate in the clinic. When an applicant misses even one requirement, the examiner cannot issue the certificate on the spot. The file must go to the FAA for review. Pilots can review all qualifying conditions on the list of CACI conditions and worksheets.
Acceptable Certification Criteria and the FAA Hematocrit Limit
To qualify for same-day issuance, an applicant must satisfy four clinical criteria on the worksheet. These standards confirm that testosterone treatment remains stable and safe for flight duties.
The FAA hematocrit limit for testosterone is 54% or less. This matches major clinical guidelines. The worksheet cites the Endocrine Society clinical practice guideline titled Testosterone Therapy in Men With Hypogonadism. In addition, the American Urological Association (AUA) testosterone deficiency guideline uses a hematocrit of 54% or greater as the polycythemia threshold. The AUA advises clinicians to measure hemoglobin and hematocrit at baseline and follow them during therapy. A hematocrit above 54% stops immediate issuance. We discuss managing elevated red blood cells in our guide on high hematocrit on TRT, alongside general risks in TRT side effects and risks.
- Condition stability. Condition is stable on current regimen, no changes recommended, and no side effects which would interfere with flight duties. The worksheet notes that mild skin irritation and acne are acceptable.
- No phlebotomy requirement. The individual must not require treatment with phlebotomy.
- No thromboembolic history. No venous thromboembolic event (VTE) such as pulmonary embolism (PE) or deep vein thrombosis (DVT).
- Normal laboratory values. A complete blood count (CBC) performed within the last 90 days verifies hematocrit is 54% or less.
Clinical Documentation Requirements and the 90-Day Progress Note
Your Aviation Medical Examiner must review a detailed Clinical Progress Note generated from a clinic visit no more than 90 days prior to the exam. Timing is strict. The note must come from a clinic visit with your urologist, endocrinologist, or treating physician. It must document that your condition is stable on your current regimen. It must also confirm that no treatment changes are recommended and no adverse symptoms exist.
As an alternative, the FAA accepts a completed Low Testosterone (Low T) Hypogonadism Status Summary form. Your treating doctor can complete this standardized summary in place of a custom clinic progress note. Your laboratory results must also satisfy the 90-day window. A complete blood count performed outside those 90 days is invalid for CACI clearance. Your examiner cannot accept expired lab panels.
Approved Medications and Mandatory Ground Trials
The FAA worksheet accepts six specific medications for treating low testosterone. These include anastrozole, clomiphene citrate, human chorionic gonadotropin (HCG), testosterone pellets, oral or injectable testosterone, and tamoxifen. Testosterone pellets are named on the worksheet as an accepted formulation.
Two medications require mandatory ground trials before a pilot can fly. Clomiphene citrate requires a 14-day initial ground trial. During this trial, the pilot cannot fly. The examiner must confirm no visual side effects are present before issuing a medical certificate. Human chorionic gonadotropin requires a 7-day initial ground trial.
Enclomiphene citrate is not acceptable on this worksheet. This exclusion catches many pilots off guard. Physicians frequently prescribe enclomiphene off-label to support testosterone while protecting fertility. However, an applicant taking enclomiphene cannot receive same-day CACI clearance. We compare these compounds in our reviews of enclomiphene vs TRT and clomiphene vs enclomiphene.
| Medication | Ground Trial Requirement | Worksheet Limitations |
|---|---|---|
| Anastrozole | None specified | Must be documented as stable without side effects |
| Clomiphene citrate | 14-day initial ground trial | AME must confirm no visual side effects are present |
| Human chorionic gonadotropin (HCG) | 7-day initial ground trial | Must confirm tolerance before flight duties resume |
| Pellets | None specified | Named on the worksheet as an accepted formulation |
| Testosterone (oral or injectable) | None specified | Regimen must be stable on the current dose |
| Tamoxifen | None specified | Condition must remain stable on current therapy |
Delivery Routes and Formulations on the CACI Worksheet
The CACI worksheet specifies testosterone as oral or injectable, along with pellets. It does not name transdermal gels, creams, patches, or nasal gel. This omission creates uncertainty for pilots using topical formulations.
If you use a transdermal gel, cream, patch, or nasal spray, raise it with your AME before the physical. Review the CACI Low T worksheet with your examiner in advance. Do not assume that unlisted routes are automatically disqualifying. Never change or stop a prescribed medication without guidance from your treating physician.
Delivery route changes how much red blood cell production rises. Erythrocytosis risk is highest with injectable testosterone and lower with transdermal routes. This finding comes from a network meta-analysis of 29 placebo-controlled randomized trials covering 3,393 men, published in the Journal of Urology. Injections create concentration peaks that stimulate red cell mass. We analyze delivery methods in detail in our comparison of TRT delivery routes compared.
Submission Frequency by FAA Medical Certificate Class
If you hold an FAA first-class or second-class medical certificate, you must provide your testosterone clinical information annually. Third-class applicants must provide the information with each required exam. A completed Low Testosterone (Low T) Hypogonadism Status Summary form can be used in place of the Clinical Progress Note.
The Clinical Progress Note must be generated from a clinic visit with your urologist, endocrinologist, or treating physician no more than 90 days prior to the AME exam. Your complete blood count (CBC) must have been performed within the last 90 days and must verify a hematocrit of 54% or less.
| Medical Certificate Class | Submission Cadence | Required Clinical Records |
|---|---|---|
| First-Class | Annually | Progress note or Status Summary within 90 days, CBC verifying hematocrit 54% or less |
| Second-Class | Annually | Progress note or Status Summary within 90 days, CBC verifying hematocrit 54% or less |
| Third-Class | With each required exam | Progress note or Status Summary within 90 days, CBC verifying hematocrit 54% or less |
AME Evaluation and the Block 60 Deferral Process
Your Aviation Medical Examiner records the certification decision in Block 60 of your medical application. The FAA requires examiners to choose one of three specific entries. If you meet all criteria, the examiner writes 'CACI qualified Hypogonadism'. Under this finding, supporting clinical documents do not need to be submitted to the FAA. The examiner issues your medical certificate immediately.
If you held a previous special issuance, the entry reads 'Has current OR previous SI/AASI but now CACI qualified Hypogonadism'. If you fail any standard, the examiner writes 'NOT CACI qualified Hypogonadism. I have deferred.' In a deferral, the examiner submits all supporting documents directly to the FAA.
Where an applicant is not CACI qualified, the case moves to the FAA for review. The agency evaluates whether the pilot qualifies for an AME Assisted Special Issuance (AASI). The FAA maintains a dedicated AASI Low T hypogonadism worksheet for these cases.
- CACI qualified Hypogonadism. Entered when all worksheet criteria are met. Documents do not need to be submitted to the FAA.
- Has current OR previous SI/AASI but now CACI qualified Hypogonadism. Entered for pilots transitioning from a special issuance to standard CACI clearance.
- NOT CACI qualified Hypogonadism. I have deferred. Entered when any worksheet criterion is missed. All supporting records are submitted to the FAA.
Disqualification Triggers and Criteria for Deferral
An applicant on testosterone therapy is disqualified from immediate CACI clearance if any worksheet requirement is missed. Several distinct clinical findings trigger an automatic deferral.
- A hematocrit above 54%.
- A requirement for therapeutic phlebotomy.
- Any history of venous thromboembolism, including pulmonary embolism or deep vein thrombosis.
- A medication the worksheet does not list, such as enclomiphene citrate.
- An incomplete ground trial.
- Clinical notes or lab results older than 90 days.
Who This Path Does Not Cover
This clearance pathway is not for pilots with unstable hormone therapy or any history of a venous thromboembolic event. If you need regular phlebotomy to manage red blood cell volume, you cannot use CACI. What would change our guidance is an update to the FAA worksheet itself. The FAA Low T worksheet carries a revision date of 04/29/2026. If the FAA revises accepted medications or clinical limits, the newly published FAA version governs. Review your laboratory results with your treating physician before scheduling your flight physical to ensure your documentation satisfies every CACI requirement.
It also does not cover anyone certified under a different occupational regime. A firefighter is assessed against an occupational medical standard that carries no endocrine assay in its routine evaluation, where the haematocrit question is raised by heat strain and dehydration on the fireground rather than by a certification limit. None of the CACI criteria above carry over to it.
Frequently Asked Questions
Can a pilot fly while on testosterone replacement therapy?
Yes, pilots can fly while on testosterone replacement therapy. An Aviation Medical Examiner can issue a medical certificate at the exam under the CACI program if four criteria are met. Your condition must be stable on your current dose with no flight-interfering side effects. You must not require therapeutic phlebotomy. You must have no history of venous thromboembolism, such as pulmonary embolism or deep vein thrombosis. Your complete blood count within the last 90 days must verify a hematocrit of 54% or less. If your records meet these standards, the examiner issues your certificate immediately.
What hematocrit level disqualifies a pilot on testosterone?
A hematocrit level above 54% disqualifies a pilot from same-day CACI clearance. The FAA CACI worksheet requires a complete blood count performed within the last 90 days verifying hematocrit is 54% or less. This threshold aligns with the American Urological Association guideline, which identifies 54% or greater as the polycythemia threshold. If your hematocrit is above 54%, the examiner cannot issue your certificate under CACI and must defer your file to the FAA. Regular blood monitoring helps pilots identify rising red blood cell volume before an exam.
Does the FAA accept enclomiphene for pilots?
No, the FAA does not accept enclomiphene citrate on the CACI Low Testosterone worksheet. While enclomiphene is widely used for hypogonadism to preserve fertility, the worksheet limits approved medications to anastrozole, clomiphene citrate, human chorionic gonadotropin, testosterone pellets, oral or injectable testosterone, and tamoxifen. An applicant taking enclomiphene cannot receive same-day CACI issuance. Any change to a prescription is a medical decision for the pilot and treating physician, not something to adjust based on a worksheet.
How recent do my labs have to be for an FAA medical exam on TRT?
Your laboratory results and clinical documentation must be no more than 90 days old at the time of your exam. The Aviation Medical Examiner must review a complete blood count verifying your hematocrit is 54% or less drawn within this 90-day window. In addition, the examiner must review a Clinical Progress Note from a clinic visit within the last 90 days, or a completed Low Testosterone Status Summary form. Lab panels or clinical notes older than 90 days prevent immediate issuance and require updated records.
Do I have to tell my AME I am on testosterone?
Yes, your Aviation Medical Examiner must evaluate your testosterone therapy during your exam. Under the CACI protocol, the examiner must review a Clinical Progress Note from your treating physician dated within the last 90 days, or a completed Status Summary form. The therapy is assessed directly against the FAA worksheet criteria. Without that note, the examiner cannot establish CACI qualification and must defer the file to the FAA. Bringing compliant records ensures your examiner can issue your certificate at the visit.
What happens if my AME defers my medical certificate?
When an AME defers your medical certificate, the examiner cannot issue clearance at the clinic visit and must forward your records to the FAA for review. In Block 60 of your medical application, the examiner notes that you are not CACI qualified and that the case is deferred. The FAA then evaluates your file to determine if you qualify for an AME Assisted Special Issuance (AASI). This process delays your certification while the agency reviews your clinical history and lab results.
How often do first-class pilots have to resubmit testosterone paperwork?
First-class and second-class pilots must provide current testosterone documentation annually. For each annual submission, the pilot must present a Clinical Progress Note from their treating physician or a completed Status Summary form generated within the preceding 90 days. The paperwork must confirm stability on the current regimen and include a complete blood count verifying hematocrit is 54% or less. Third-class pilots must provide this information with each required exam rather than annually. Keeping records organized ensures smooth annual renewals.
Does a ground trial mean I cannot fly at all?
Yes, during a mandatory ground trial, you cannot exercise pilot privileges. A ground trial requires you to remain on the ground to confirm that you tolerate a medication without adverse effects that could impair flight duties. The FAA worksheet mandates a 14-day ground trial for clomiphene citrate, during which the examiner must verify no visual disturbances occur. Human chorionic gonadotropin requires a 7-day initial ground trial. Once the trial period concludes without adverse reactions, you may proceed with certification.