Testosterone Enanthate (generic Delatestryl) — CareFirst (Caremark)
Primary or hypogonadotropic hypogonadism
Initial criteria
- Requested drug is not being prescribed for age-related hypogonadism (late-onset hypogonadism)
- Before start of testosterone therapy, patient has at least two confirmed low morning testosterone levels according to current practice guidelines or standard lab reference values
Reauthorization criteria
- Requested drug is not being prescribed for age-related hypogonadism (late-onset hypogonadism)
- Before start of testosterone therapy, patient had a confirmed low morning testosterone level according to current practice guidelines or standard lab reference values
Approval duration
36 months