| Anthem Blue Cross (HMO, PPO, EPO) |
| Lupron Depot (1-Month) (leuprolide) |
| Drugs for Cancer : Drugs for Cancer |
- Prior Authorization: Diabetic Medical Supplies:
Documented Diagnosis: Yes
Duration: 1 plan year
Reauthorization Required: Yes
- Prior Authorization: PA Applies
- Available only through Specialty Pharmacy;
- Quantity Limit: 1 bottle per 30 day(s).
- Prior Authorization: Solid Tumor with NTRK Gene Fusion:
Documented Diagnosis: Yes
Medical Test Required: Yes
Duration: 1 year(s)
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