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June 2016

Reminder: Depo®-Testosterone requires prior authorization

The prescription drug Depo®-Testosterone requires a medical drug prior authorization for all Blue Cross Blue Shield of Michigan members.

As of July 1, 2015, the following testosterone replacement therapy medications were added to the prior authorization program:

Name-brand drug

Generic name

HCPCS code

Aveed®

Testosterone undecanoate

J3145

Delatestryl®

Testosterone enanthate

J3121

Depo®-Testosterone

Testosterone cypionate

J1071

Testopel®

Testosterone pellet

S0189
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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.
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