Delatestryl — CareFirst (Caremark)

Initial criteria

• The requested drug is NOT being prescribed for age-related hypogonadism (also referred to as late-onset hypogonadism).
• Before the start of testosterone therapy, the patient has at least TWO confirmed low morning testosterone levels according to current practice guidelines or standard lab reference values.

Reauthorization criteria

• Authorization may be granted when the requested drug is being prescribed for primary or hypogonadotropic hypogonadism when ALL of the following criteria are met:
• The requested drug is NOT being prescribed for age-related hypogonadism (also referred to as late-onset hypogonadism).
• Before the patient started testosterone therapy, the patient had a confirmed low morning testosterone level according to current practice guidelines or standard lab reference values.

Approval duration

36 months