Delatestryl — CareFirst (Caremark)

Initial criteria

• The requested drug is being prescribed for inoperable metastatic breast cancer in a patient who is 1 to 5 years postmenopausal AND had an incomplete response to other therapy for metastatic breast cancer.
• The requested drug is NOT being prescribed for age-related hypogonadism (also referred to as late-onset hypogonadism).
• The request is for intramuscular testosterone enanthate injection (generic Delatestryl).

Reauthorization criteria

• All patients requesting authorization for continuation of therapy must meet all requirements in the coverage criteria section.

Approval duration

36 months