| Anthem Blue Cross (HMO, PPO, EPO) |
| Lupron Depot (4-Month) (leuprolide (4 month)) |
| Drugs for Cancer : Drugs for Cancer |
- Quantity Limit: 1 kit per 112 day(s).
- Prior Authorization: Endometriosis:
Documented Diagnosis: Yes
Duration: 6 Month(s)
Reauthorization Required: Yes
Metastatic Prostate Cancer, Non-Metastatic Prostate Cancer, Uterine Fibroids:
Documented Diagnosis: Yes
- Available only through Specialty Pharmacy;
For FAX form click HERE
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
Log in to Surescripts
Log in to CoverMyMeds; For details on GNRH criteria for drug coverage click HERE | For details on Infertility criteria for drug coverage click HERE;
- PA Applies
- Endometriosis:
Duration: 6 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 6 month(s)
Surgical Ablation to Prevent Recurrence Required: No
Documented Diagnosis: Yes
Metastatic Prostate Cancer:
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): 1 of Accredo Health Group, Inc.;Apothecary By Design;Circle Care;The Pharmacy at Maine Medical Center
Reauthorization Required: No
Duration of Reauthorization: N/A
Non-Metastatic Prostate Cancer:
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Uterine Fibroids:
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Diagnosis Requirement(s): Preoperative treatment as adjunct to surgery
Documented Diagnosis: Yes
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