Product Details
Androgel
Testosterone1%
5-g Unit-Dose Foil Packet
DIN/PIN/NPN
02245346
Manufacturer
Solvay Pharma Inc.
Formulary Listing Date
2005-02-22
Unit Price
4.4145
Amount MOH Pays
2.9575
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
G03BA03
Interchangeable Products
| DIN/ PIN/ NPN | Brand name | Unit Price | Amount MOH pays |
|---|---|---|---|
| 02463806 | Taro-Testosterone Gel | 2.9575 | 2.9575 |
| 02245346 | Androgel | 4.4145 | 2.9575 |
LU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 397 | 1 year | For male patients with confirmed low morning serum testosterone levels associated with documented, symptomatic hypothalamic, pituitary or testicular disease, or in HIV-infected patients. Note: Older males with nonspecific symptoms of fatigue, malaise, depression who have a low normal random testosterone level do not satisfy these criteria. |