ANDROGENIC AGENTS | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
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
FORTESTA 10 MG GEL PUMP testosterone	63481018316 ENDO PHARM INC.	Yes	Yes	Medicaid CHIP CSHCN
NATESTO NASAL 5.5 MG/0.122 GM testosterone	42667551101 ACERUS PHARMA	Yes	Yes	Medicaid CHIP CSHCN
TESTIM 1% (50MG) GEL testosterone	66887000105 AUXILIUM/ENDO P	Yes	Yes	Medicaid CHIP CSHCN
TESTOSTERONE 1% (25MG/2.5G) PK testosterone	00591321630 ACTAVIS/TEVA	Yes	Yes	Medicaid CHIP CSHCN
TESTOSTERONE 1% (25MG/2.5G) PK testosterone	64380015102 STRIDES PHARMA	Yes	Yes	Medicaid CHIP CSHCN
TESTOSTERONE 1% (50 MG/5 G) PK testosterone	64380015202 STRIDES PHARMA	Yes	Yes	Medicaid CHIP CSHCN
TESTOSTERONE 1% (50 MG/5 G) PK testosterone	00591321730 ACTAVIS/TEVA	Yes	Yes	Medicaid CHIP CSHCN
TESTOSTERONE 1% (50 MG/5 G) PK testosterone	21922001902 ENCUBE ETHICALS	Yes	Yes	Medicaid CHIP CSHCN