Leuprolide Injections Prior Authorization Criteria

General Prior Authorization Request Form

Covered Uses

All FDA approved indications not otherwise excluded from Part D (FDA labeled indication)

• Eligard - Advanced prostatic cancer when orchiectomy or estrogen administrations are either not indicated or unacceptable to the patient
• Lupron - Endometriosis including pain relief and reduction of endometriosis lesions, precocious puberty and fibroids

Exclusion Criteria

None

Required Medical Information

None

Age Restrictions

None

Prescriber Restrictions

None

Coverage Duration

Authorized up to six (6) months depending on the refills written in the prescription.

Other Criteria

None