Androgens, Oral

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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.

Generic Name Brand Name Form PDL
Current Drug Use Criteria New Drug Evaluation
methyltestosterone METHYLTESTOSTERONE CAPSULE PA Document  
methyltestosterone METHITEST TABLET PA Document  
prasterone (DHEA) INTRAROSA INSERT PA Document May 25, 2017
testosterone undecanoate JATENZO CAPSULE PA Document  
testosterone undecanoate TLANDO CAPSULE PA Document