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testosterone enanthate injection — CareFirst (Caremark)

Breast cancer (hormone-responsive tumor)

Initial criteria

  • Patient is premenopausal with breast cancer
  • Patient has benefited from oophorectomy
  • Patient is considered to have a hormone-responsive tumor
  • Requested drug is NOT being prescribed for age-related hypogonadism
  • Request is for intramuscular testosterone enanthate injection (generic Delatestryl)