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Testosterone Enanthate Injection (generic Delatestryl) — CareFirst (Caremark)

Metastatic mammary cancer (in women postmenopausal or premenopausal after oophorectomy)

Initial criteria

  • Patient has a diagnosis consistent with one of the FDA-approved indications
  • If used for delayed puberty, must be in carefully selected males after evaluation of bone age every 6 months
  • If used for metastatic mammary cancer, must be in women with inoperable hormone-responsive tumors who are 1–5 years postmenopausal or premenopausal women who have benefited from oophorectomy
  • The requested product is NOT being used for age-related (late-onset) hypogonadism