testosterone enanthate injection (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 request is for intramuscular testosterone enanthate injection (generic Delatestryl) OR testosterone propionate implant pellet (Testopel)

Reauthorization criteria

• Patient continues to meet all initial coverage criteria

Approval duration

36 months