Androgens, Topical & Parenteral
PDL Reference Documents
Drug Use Review Documents
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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.
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.
| NDC | Brand Name | Generic Name | Form | Strength | PDL Status |
Rebate | Current Drug Use Criteria |
|---|---|---|---|---|---|---|---|
| 66887000101 | TESTIM | testosterone | GEL (GRAM) | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 66887000105 | TESTIM | testosterone | GEL (GRAM) | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 00591352426 | TESTOSTERONE | testosterone | GEL (GRAM) | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 00591352430 | TESTOSTERONE | testosterone | GEL (GRAM) | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 00832112005 | TESTOSTERONE | testosterone | GEL (GRAM) | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 00591236360 | TESTOSTERONE | testosterone | GEL MD PMP | 10 mg/0.5 gram per actuation (2 %) | N | Y | PA Document |
| 00591292102 | TESTOSTERONE | testosterone | GEL MD PMP | 12.5 mg/1.25 gram per actuation (1 %) | Y | Y | PA Document |
| 00591292118 | TESTOSTERONE | testosterone | GEL MD PMP | 12.5 mg/1.25 gram per actuation (1 %) | Y | Y | PA Document |
| 00832112140 | TESTOSTERONE | testosterone | GEL MD PMP | 12.5 mg/1.25 gram per actuation (1 %) | Y | Y | PA Document |
| 00832112142 | TESTOSTERONE | testosterone | GEL MD PMP | 12.5 mg/1.25 gram per actuation (1 %) | Y | Y | PA Document |
| 21922001947 | TESTOSTERONE | testosterone | GEL MD PMP | 12.5 mg/1.25 gram per actuation (1 %) | Y | Y | PA Document |
| 66993095344 | TESTOSTERONE | testosterone | GEL MD PMP | 12.5 mg/1.25 gram per actuation (1 %) | Y | Y | PA Document |
| 66993095388 | TESTOSTERONE | testosterone | GEL MD PMP | 12.5 mg/1.25 gram per actuation (1 %) | Y | Y | PA Document |
| 00051846233 | ANDROGEL | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 00591292418 | TESTOSTERONE | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 16714096701 | TESTOSTERONE | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 21922003020 | TESTOSTERONE | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 24979007815 | TESTOSTERONE | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 45802075401 | TESTOSTERONE | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 66993095188 | TESTOSTERONE | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 68180094111 | TESTOSTERONE | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 69238101302 | TESTOSTERONE | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 70700011221 | TESTOSTERONE | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 72603026501 | TESTOSTERONE | testosterone | GEL MD PMP | 20.25 mg/1.25 gram per actuation (1.62 %) | Y | Y | PA Document |
| 42667551101 | NATESTO | testosterone | GEL MD PMP | 5.5 mg/0.122 gram per actuation | N | Y | PA Document |
| 16714096801 | TESTOSTERONE | testosterone | GEL PACKET | 20.25 mg/1.25 gram (1.62 %) | Y | Y | PA Document |
| 16714096802 | TESTOSTERONE | testosterone | GEL PACKET | 20.25 mg/1.25 gram (1.62 %) | Y | Y | PA Document |
| 45802028103 | TESTOSTERONE | testosterone | GEL PACKET | 20.25 mg/1.25 gram (1.62 %) | Y | Y | PA Document |
| 45802028139 | TESTOSTERONE | testosterone | GEL PACKET | 20.25 mg/1.25 gram (1.62 %) | Y | Y | PA Document |
| 00591321617 | TESTOSTERONE | testosterone | GEL PACKET | 25 mg/2.5 gram (1 %) | Y | Y | PA Document |
| 00591321630 | TESTOSTERONE | testosterone | GEL PACKET | 25 mg/2.5 gram (1 %) | Y | Y | PA Document |
| 21922001952 | TESTOSTERONE | testosterone | GEL PACKET | 25 mg/2.5 gram (1 %) | Y | Y | PA Document |
| 64380015101 | TESTOSTERONE | testosterone | GEL PACKET | 25 mg/2.5 gram (1 %) | Y | Y | PA Document |
| 64380015102 | TESTOSTERONE | testosterone | GEL PACKET | 25 mg/2.5 gram (1 %) | Y | Y | PA Document |
| 00591292625 | TESTOSTERONE | testosterone | GEL PACKET | 40.5 mg/2.5 gram (1.62 %) | Y | Y | PA Document |
| 00591292630 | TESTOSTERONE | testosterone | GEL PACKET | 40.5 mg/2.5 gram (1.62 %) | Y | Y | PA Document |
| 16714096901 | TESTOSTERONE | testosterone | GEL PACKET | 40.5 mg/2.5 gram (1.62 %) | Y | Y | PA Document |
| 16714096902 | TESTOSTERONE | testosterone | GEL PACKET | 40.5 mg/2.5 gram (1.62 %) | Y | Y | PA Document |
| 45802036602 | TESTOSTERONE | testosterone | GEL PACKET | 40.5 mg/2.5 gram (1.62 %) | Y | Y | PA Document |
| 45802036665 | TESTOSTERONE | testosterone | GEL PACKET | 40.5 mg/2.5 gram (1.62 %) | Y | Y | PA Document |
| 00591321726 | TESTOSTERONE | testosterone | GEL PACKET | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 00591321730 | TESTOSTERONE | testosterone | GEL PACKET | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 00832112035 | TESTOSTERONE | testosterone | GEL PACKET | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 00832112089 | TESTOSTERONE | testosterone | GEL PACKET | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 21922001902 | TESTOSTERONE | testosterone | GEL PACKET | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 64380015201 | TESTOSTERONE | testosterone | GEL PACKET | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 64380015202 | TESTOSTERONE | testosterone | GEL PACKET | 50 mg/5 gram (1 %) | Y | Y | PA Document |
| 66887000401 | TESTOPEL | testosterone | PELLET(EA) | 75 mg | Y | PA Document | |
| 66887000410 | TESTOPEL | testosterone | PELLET(EA) | 75 mg | Y | PA Document | |
| 66887000420 | TESTOPEL | testosterone | PELLET(EA) | 75 mg | Y | PA Document | |
| 00591211481 | TESTOSTERONE | testosterone | SOL MD PMP | 30 mg/1.5 mL per actuation | N | Y | PA Document |
| 24979013026 | TESTOSTERONE | testosterone | SOL MD PMP | 30 mg/1.5 mL per actuation | N | Y | PA Document |
| 45802061001 | TESTOSTERONE | testosterone | SOL MD PMP | 30 mg/1.5 mL per actuation | N | Y | PA Document |
| 68180094311 | TESTOSTERONE | testosterone | SOL MD PMP | 30 mg/1.5 mL per actuation | N | Y | PA Document |
| 69097036344 | TESTOSTERONE | testosterone | SOL MD PMP | 30 mg/1.5 mL per actuation | N | Y | PA Document |
| 24338005501 | AZMIRO | testosterone cypionate | SYRINGE | 200 mg/mL | N | Y | PA Document |
| 00009008510 | DEPO-TESTOSTERONE | testosterone cypionate | VIAL | 100 mg/mL | Y | Y | PA Document |
| 00009034702 | DEPO-TESTOSTERONE | testosterone cypionate | VIAL | 100 mg/mL | Y | Y | PA Document |
| 00409655701 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 100 mg/mL | Y | Y | PA Document |
| 55150027601 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 100 mg/mL | Y | Y | PA Document |
| 62756001740 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 100 mg/mL | Y | Y | PA Document |
| 69097053637 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 100 mg/mL | Y | Y | PA Document |
| 70700028822 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 100 mg/mL | Y | Y | PA Document |
| 00009008601 | DEPO-TESTOSTERONE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00009041701 | DEPO-TESTOSTERONE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00009041702 | DEPO-TESTOSTERONE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00143900501 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00143965901 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00143972601 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00409656201 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00409656220 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00574082001 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00574082010 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00574082701 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00574082710 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 47781091022 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 47781091091 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 47781091193 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 52536062501 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 52536062510 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 55150027701 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 55150027801 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 62756001540 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 62756001640 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 69097053731 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 69097080232 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 70700028922 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 70700029022 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 72603028601 | TESTOSTERONE CYPIONATE | testosterone cypionate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 54436020002 | XYOSTED | testosterone enanthate | AUTO INJCT | 100 mg/0.5 mL | N | Y | PA Document |
| 54436020004 | XYOSTED | testosterone enanthate | AUTO INJCT | 100 mg/0.5 mL | N | Y | PA Document |
| 54436025002 | XYOSTED | testosterone enanthate | AUTO INJCT | 50 mg/0.5 mL | N | Y | PA Document |
| 54436025004 | XYOSTED | testosterone enanthate | AUTO INJCT | 50 mg/0.5 mL | N | Y | PA Document |
| 54436027502 | XYOSTED | testosterone enanthate | AUTO INJCT | 75 mg/0.5 mL | N | Y | PA Document |
| 54436027504 | XYOSTED | testosterone enanthate | AUTO INJCT | 75 mg/0.5 mL | N | Y | PA Document |
| 00143975001 | TESTOSTERONE ENANTHATE | testosterone enanthate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 00591322126 | TESTOSTERONE ENANTHATE | testosterone enanthate | VIAL | 200 mg/mL | Y | Y | PA Document |
| 67979051143 | AVEED | testosterone undecanoate | VIAL | 750 mg/3 mL (250 mg/mL) | N | Y | PA Document |