Androgel 1.62% — CareFirst (Caremark)
Inoperable metastatic breast cancer
Initial criteria
- Patient is 1 to 5 years postmenopausal AND had an incomplete response to other therapy for metastatic breast cancer
- Requested drug is NOT being prescribed for age-related hypogonadism (also referred to as late-onset hypogonadism)
- Request is for intramuscular testosterone enanthate injection (generic Delatestryl)
Reauthorization criteria
- All continuation of therapy requests must meet all requirements in the coverage criteria section
Approval duration
36 months