| Anthem Blue Cross (HMO, PPO, EPO) |
| Eligard (leuprolide (6 month)) |
| Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: PA_APPLIES
- Minimum Age: 6 Years; Maximum Age: N.A.;
- Quantity Limit: 204 lancets per 30 day(s).
- 1;
- Assisted Reproductive Technology (ART):
Duration: 2 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Specialty Pharmacy Provider(s): 1 of Avella Specialty Pharmacy;Freedom Fertility Pharmacy
Reauthorization Required: No
Duration of Reauthorization: N/A
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