Product Details

Delatestryl

Testosterone Enanthate
1000 mg/5 mL
Oily Solution for Injection
5-mL Vial Pack

DIN/PIN/NPN

00029246

Manufacturer

Valeant Canada Ltd.

Formulary Listing Date

1996-10-01  

Unit Price

67.3056

Amount MOH Pays

48.5377

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
00029246 Delatestryl 67.3056 48.5377
02536315 Testosterone Enanthate Injection, USP 48.5377 48.5377
 

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

Therapeutic Class Reimbursement Criteria
Unclassified EAP Drugs

These drugs are not currently listed in the Exceptional Access Program Reimbursement Criteria for Frequently Requested Drugs – August 8, 2023 Edition

Physicians may wish to contact the EAP directly by phone at 416-327-8109 or 1-866-811-9893 or by email at EAPFeedback.MOH@ontario.ca to see if an unlisted drug product and/or indication may be considered for EAP funding.

Product Monograph

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