testosterone enanthate injection — 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

• All patients requesting authorization for continuation of therapy must meet all requirements in the coverage criteria section.

Approval duration

36 months