methyltestosterone — CareFirst (Caremark)

Preferred products

• topical testosterone
• injectable testosterone

Initial criteria

• The requested drug is being prescribed for delayed puberty.
• The requested drug is NOT being prescribed for age-related hypogonadism (also referred to as late-onset hypogonadism).
• The patient meets ONE of the following: has experienced an inadequate treatment response to an alternative testosterone product (e.g., topical testosterone, injectable testosterone); has experienced an intolerance to an alternative testosterone product; or has a contraindication that would prohibit a trial of alternative testosterone products.

Reauthorization criteria

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

Approval duration

36 months