Product Details

Androgel

Testosterone
1%

2.5-g Unit-Dose Foil Packet

DIN/PIN/NPN

02245345

Manufacturer

Solvay Pharma Inc.

Formulary Listing Date

2005-02-22  

Unit Price

2.4965

Amount MOH Pays

1.6726

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
02463792 Taro-Testosterone Gel 1.6726 1.6726
02245345 Androgel 2.4965 1.6726
 

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.

 

EAP Criteria

NO

Product Monograph

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