testosterone enanthate injection (generic Delatestryl) — CareFirst (Caremark)

Initial criteria

• Patient is male (except for breast cancer use in women)
• Diagnosis is one of the following: primary hypogonadism or hypogonadotropic hypogonadism OR other supported indication per FDA‑approved labeling or compendial use
• The requested drug is NOT being prescribed for age‑related hypogonadism (also referred to as late‑onset hypogonadism)
• Safety and efficacy established in appropriate age group (for topical, nasal, or testosterone undecanoate products, use is in adult males unless otherwise noted)
• For breast cancer indication: patient is premenopausal with breast cancer, has benefited from oophorectomy, AND has a hormone‑responsive tumor, AND requested drug is intramuscular testosterone enanthate injection (generic Delatestryl)

Reauthorization criteria

• Continuation of therapy may be approved if patient continues to meet initial criteria and is experiencing clinical benefit without unacceptable toxicity

Approval duration

12 months