Anthem Blue Cross (HMO, PPO, EPO)
Lupron Depot (Syrg) (leuprolide)
Drugs for Cancer : Drugs for Cancer
  • 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

    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

  • Prior Authorization: Endometriosis:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Metastatic Prostate Cancer, Uterine Fibroids:
    Documented Diagnosis: Yes

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