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Depo-Testosterone — CareFirst (Caremark)

Metastatic mammary cancer in women with advancing inoperable metastatic (skeletal) mammary cancer who are one to five years postmenopausal or premenopausal women with breast cancer who have benefited from oophorectomy and are considered to have a hormone-responsive tumor

Initial criteria

  • The requested drug is NOT being prescribed for age-related hypogonadism (also referred to as late-onset hypogonadism)
  • Authorization may be granted when the requested drug is being prescribed for a premenopausal patient with breast cancer who has benefited from oophorectomy AND is considered to have a hormone-responsive tumor
  • The request is for intramuscular testosterone enanthate injection (generic Delatestryl)