Lupron Depot 11.25 mg — Highmark
uterine leiomyomata
Initial criteria
- Diagnosis of uterine leiomyomata (ICD-10: D25)
- Member will be using Lupron Depot concomitantly with iron therapy
Reauthorization criteria
- Prescriber attests that the member has experienced a positive clinical response to therapy
- Member requires continued therapy with the requested product
Approval duration
12 months