UnitedHealthcare
Lupron Depot-Ped (3-Month) (leuprolide (pediatric 3 month))
Hormones : Drugs for Women
  • Prior Authorization: Central Precocious Puberty:
    Documented Diagnosis: Yes
    Medical Test Required: Yes
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Central Precocious Puberty:
    Duration: 12 Month(s)
    Specialist Required: Yes
    Medical Test Required: Yes
    Specialist Type(s): Pediatric Endocrinologist
    Reauthorization Required: Yes
    Duration of Reauthorization: = 12 month(s)
    Onset of Secondary Sexual Characteristics for Females: < 8 year(s)
    Onset of Secondary Sexual Characteristics for Males: < 9 year(s)
    Diagnostic Evaluation Requirement(s): 2 of Bone age advanced beyond the chronological age;Diagnostic imaging of brain required;Pubertal luteinizing hormone (LH) response to a GnRH stimulation test
    Documented Diagnosis: Yes

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