| Anthem Blue Cross (HMO, PPO, EPO) |
| Lupron Depot (1-Month) (leuprolide) |
| Hormones : Drugs for Women |
- Post-herpetic Neuralgia:
Age Requirement: >= 18
Duration: 6 Month(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
- Quantity Limit: limit maximum 750 mL PER 30 day(s)
- Prior Authorization: PA_APPLIES
- Quantity Limit: limit maximum 0.50 EA PER 1 day(s)
- May be covered under Medical Benefit.
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