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 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, ALL of the following criteria are met:
• — 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), with collaborated care with a mental health provider
• — The patient has reached, or has previously reached, Tanner stage 2 of puberty or greater

Reauthorization criteria

• Patient continues to meet all initial coverage criteria

Approval duration

36 months