Anthem Blue Cross (HMO, PPO, EPO)
Lupron Depot (3-Month) (leuprolide (3 month))
Drugs for Cancer : Drugs for Cancer
  • 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

  • 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): 1 of Anemia associated with Uterine Fibroids;Preoperative treatment as adjunct to surgery
    Documented Diagnosis: Yes

  • Quantity Limit: 1 kit per 84 day(s).
  • PA Applies
  • 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;