ANDROGENS

Covered Uses:	All FDA approved indications not otherwise excluded from Part D.
Exclusion Criteria:
Required Medical Information:	Coverage is provided for females for the palliative treatment of breast cancer. Coverage is provided for males for delayed puberty or the treatment of hypogonadism in situations where the patient has symptoms suggestive of androgen deficiency AND either a baseline (pre-treatment) serum testosterone level of less than or equal to 300 ng/dL (less than 10.4 nmol/L) or a baseline serum free testosterone levels below the lower limit of normal for the reporting lab.
Age Restrictions:
Prescriber Restrictions:
Coverage Duration:	All indications 5 years, except delayed puberty: 6 months
Other Criteria:

Last Modified on 12/19/2012