Anthem Blue Cross (HMO, PPO, EPO)
Lupron Depot-Ped (3-Month) (leuprolide (pediatric 3 month))
Hormones : Drugs for Women
  • Quantity Limit: 1 kit per 84 day(s).
  • Prior Authorization: Central Precocious Puberty:
    Documented Diagnosis: Yes

  • Central Precocious Puberty:
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A
    Onset of Secondary Sexual Characteristics for Females: < 8 year(s)
    Onset of Secondary Sexual Characteristics for Males: < 9 year(s)
    Documented Diagnosis: Yes

  • 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 drug coverage click HERE;
  • PA Applies