Anthem Blue Cross (HMO, PPO, EPO) |
Lupron Depot-Ped (3-Month) (leuprolide (pediatric 3 month)) |
Hormones : Drugs for Women |
- Step Therapy: ST_APPLIES
- Derm: Acne Vulgaris:
Duration: 12 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Limited to non-cosmetic use: No
- Prior Authorization: Soft Tissue Sarcoma:
Documented Diagnosis: Yes
Duration: 1 year(s)
- Medical Benefit May Apply
- Orally administered anticancer medication.
|