Prior authorization required for Depo^®-Testosterone and its generic

Depo-Testosterone and its generic, testosterone cypionate, are both part of the Medical Drug Prior Authorization Program. This drug requires a medical prior authorization, as of July 1, 2015.

Keep in mind that a prior authorization approval isn’t a guarantee of payment. Health care practitioners will need to verify coverage for medical benefits. This will help ensure appropriate utilization and address potential safety issues for these medications. Note: The prior authorization requirement doesn’t apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Blue Cross Blue Shield of Michigan won’t consider a request for coverage until we receive a physician-signed medication request form, faxed or mailed to Blue Cross, or a request uploaded to the online tool, NovoLogix^®. The standard processing time for reviewing a request is 15 days. An urgent request is reviewed within 72 hours.

The list below reflects the current National Drug Codes available for this medication:

Blue Cross reserves the right to change this list at any time.

You can find medication request forms for medications that require prior authorization by going to web-DENIS and following these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).