Androgens, Topical & Parenteral

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
testosterone VOGELXO GEL (GRAM) Y Age Restriction  
testosterone TESTOSTERONE GEL (GRAM) Y Age Restriction  
testosterone TESTIM GEL (GRAM) Y Age Restriction  
testosterone VOGELXO GEL MD PMP Y Age Restriction  
testosterone TESTOSTERONE GEL MD PMP Y Age Restriction  
testosterone ANDROGEL GEL MD PMP Y Age Restriction  
testosterone TESTOSTERONE GEL PACKET Y Age Restriction  
testosterone VOGELXO GEL PACKET Y Age Restriction  
testosterone ANDROGEL GEL PACKET Y Age Restriction  
testosterone cypionate TESTOSTERONE CYPIONATE VIAL Y Age Restriction  
testosterone cypionate DEPO-TESTOSTERONE VIAL Y Age Restriction  
testosterone enanthate TESTOSTERONE ENANTHATE VIAL Y Age Restriction  
testosterone NATESTO GEL MD PMP N Age Restriction  
testosterone FORTESTA GEL MD PMP N Age Restriction  
testosterone TESTOSTERONE GEL MD PMP N Age Restriction  
testosterone ANDRODERM PATCH TD24 N Age Restriction  
testosterone TESTOSTERONE SOL MD PMP N Age Restriction  
testosterone undecanoate AVEED VIAL N Age Restriction  
testosterone TESTOPEL PELLET(EA) Age Restriction