Testosterone Implant Pellet (Testopel) — CareFirst (Caremark)
Delayed puberty
Initial criteria
- Requested drug is not being prescribed for age-related hypogonadism (late-onset hypogonadism)
- Request is for intramuscular testosterone enanthate injection (generic Delatestryl) OR testosterone propionate implant pellet (Testopel)
Reauthorization criteria
- All continuation requests must meet initial coverage criteria
Approval duration
36 months