Testosterone Enanthate (generic Delatestryl) — CareFirst (Caremark)

Initial criteria

• The requested drug is NOT being prescribed for age-related hypogonadism (also referred to as late-onset hypogonadism).
• The patient's comorbid conditions are reasonably controlled.
• The patient has been educated on ANY contraindications AND side effects to therapy.
• Before the start of therapy, the patient has been informed of fertility preservation options.
• If the patient is age < 18 years, the requested drug is prescribed by or in consultation with a provider specialized in the care of transgender youth (e.g., pediatric endocrinologist, family or internal medicine physician, obstetrician-gynecologist) that has collaborative care with a mental health provider.
• If the patient is age < 18 years, the patient has reached or has previously reached Tanner stage 2 of puberty or greater.

Reauthorization criteria

• Must continue to meet all requirements in the coverage criteria section.

Approval duration

36 months