ANDROGENIC AGENTS | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
ANDRODERM 2 MG/24HR PATCH testosterone	00023599060 ALLERGAN INC.	Yes	No	Medicaid CHIP CSHCN
ANDRODERM 2 MG/24HR PATCH testosterone	00023599002 ALLERGAN INC.	Yes	No	Medicaid CHIP CSHCN
ANDRODERM 4 MG/24HR PATCH testosterone	00023599204 ALLERGAN INC.	Yes	No	Medicaid CHIP CSHCN
ANDRODERM 4 MG/24HR PATCH testosterone	00023599230 ALLERGAN INC.	Yes	No	Medicaid CHIP CSHCN
ANDROGEL 1.62% GEL PUMP testosterone	00051846233 ABBVIE US LLC	Yes	No	Medicaid CHIP CSHCN
TESTOSTERONE 1.62% GEL PUMP testosterone	16714096701 NORTHSTAR RX LL	Yes	No	Medicaid CHIP CSHCN
TESTOSTERONE 1.62% GEL PUMP testosterone	45802075401 PADAGIS	Yes	No	Medicaid CHIP CSHCN
TESTOSTERONE 1.62% GEL PUMP testosterone	24979007815 TWI PHARMACEUTI	Yes	No	Medicaid CHIP CSHCN
TESTOSTERONE 1.62% GEL PUMP testosterone	00591292418 ACTAVIS/TEVA	Yes	No	Medicaid CHIP CSHCN
TESTOSTERONE 1.62% GEL PUMP testosterone	70700011221 XIROMED, LLC	Yes	No	Medicaid CHIP CSHCN