Product Details
Depo-Testosterone
Testosterone Cypionate100 mg/mL
Oily Solution for Injection
10-mL Vial Pack
DIN/PIN/NPN
00030783
Manufacturer
Pfizer Canada Inc.
Formulary Listing Date
1996-10-01
Unit Price
48.1300
Amount MOH Pays
34.8780
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 |
|---|---|---|---|
| 02496003 | Taro-Testosterone Cypionate Injection | 34.8780 | 34.8780 |
| 00030783 | Depo-Testosterone | 48.1300 | 34.8780 |
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. |