Brand/Generic Name

Dosage/Strength

Status

Restrictions

Notes

Relative Cost

Anadrol-50 oxymetholone 50 mg tablet   Not Applicable Androderm testosterone 4 mg/24 hr Patch 24 hr; 2 mg/24 hour Patch 24 hr; 2.5 mg/24 hr Patch 24 hr; 5 mg/24 hr Patch 24 hr   Not Applicable AndroGel testosterone 1 % (25 mg/2.5 g) Gel in Packet; 1 %(50 mg/5 gram) Gel in Packet   $$$$ AndroGel testosterone 20.25 mg/1.25 gram (1.62 %) Gel in Metered-Dose Pump; 1.25 gram/actuation Gel in Metered-Dose Pump   $$$$ Android methyltestosterone 10 mg capsule   $$$ Axiron testosterone 30 mg/1.5 mL /actuation Solution in Metered Pump w/App   Not Applicable Danocrine danazol 200 mg capsule; 50 mg capsule; 100 mg capsule     $$$$$ Delatestryl testosterone enanthate 200 mg/mL Oil   $ Delatestryl testosterone enanthate 200 mg/mL Syringe   $ Depo-Testosterone testosterone cypionate 100 mg/mL Oil; 200 mg/mL Oil   $ Fortesta testosterone 10 mg/0.5 gram /actuation Gel in Metered-Dose Pump   Not Applicable Halotestin Fluoxymesterone Tab   $$$$$+ Oxandrin oxandrolone 2.5 mg tablet; 10 mg tablet   Not Applicable Striant testosterone 30 mg mucoadhesive System ER 12 hr   Not Applicable Testim testosterone 50 mg/5 gram (1 %) Gel   Not Applicable Winstrol Stanozolol Tab - 2mg   Not Applicable

Key for Product(s) Listed Above

Formulary Prior Authorization (PA may not be required for some benefit plans) Non-Formulary (Third tier coverage applies for selected plans) Not Reimbursed Quantity Limit Not available through mail order as 90-day supply* Step Therapy Generic Available. Brand name medication may be covered at a higher member cost or may not be covered for certain plans. Notes $Relative cost compared to others in category Specialty distribution for selected plans (Fourth or fifth tier coverage applied for selected plans)

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