Androgel 1.62% — CareFirst (Caremark)

Initial criteria

• Requested drug is NOT being prescribed for age-related hypogonadism (also referred to as late-onset hypogonadism)
• Patient’s comorbid conditions are reasonably controlled
• Patient has been educated on ANY contraindications AND side effects to therapy
• Before start of therapy, patient has been informed of fertility preservation options
• If patient age < 18 years, ALL of the following: prescribed by or in consultation with a provider specialized in the care of transgender youth (e.g., pediatric endocrinologist, family or internal medicine physician, obstetrician-gynecologist) that has collaborated care with a mental health provider; patient has reached, or has previously reached, Tanner stage 2 of puberty or greater

Reauthorization criteria

• All continuation of therapy requests must meet all requirements in the coverage criteria section

Approval duration

36 months