Androgens, Oral
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 |
|---|---|---|---|---|---|---|---|
| 00115140801 | METHYLTESTOSTERONE | methyltestosterone | CAPSULE | 10 mg | Y | PA Document | |
| 70954025510 | METHYLTESTOSTERONE | methyltestosterone | CAPSULE | 10 mg | Y | PA Document | |
| 00115703701 | METHITEST | methyltestosterone | TABLET | 10 mg | Y | PA Document | |
| 72495040128 | INTRAROSA | prasterone (DHEA) | INSERT | 6.5 mg | Y | PA Document | |
| 54436011220 | TLANDO | testosterone undecanoate | CAPSULE | 112.5 mg | Y | PA Document | |
| 74676011202 | TLANDO | testosterone undecanoate | CAPSULE | 112.5 mg | Y | PA Document | |
| 69087015812 | JATENZO | testosterone undecanoate | CAPSULE | 158 mg | Y | PA Document | |
| 69087019812 | JATENZO | testosterone undecanoate | CAPSULE | 198 mg | Y | PA Document | |
| 73352010522 | UNDECATREX | testosterone undecanoate | CAPSULE | 200 mg | Y | PA Document | |
| 69087023712 | JATENZO | testosterone undecanoate | CAPSULE | 237 mg | Y | PA Document |