Lupron Depot 22.5 mg — Highmark
advanced prostate cancer
Preferred products
- Eligard
Initial criteria
- Diagnosis of advanced prostate cancer (ICD-10: C61)
- Member has experienced therapeutic failure or intolerance to plan-preferred Eligard
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