Lupron Depot (leuprolide acetate) — Medica

Initial criteria

• Patient has tried ONE of the following unless contraindicated (A, B, or C):
• A) A contraceptive (e.g., combination oral contraceptives, levonorgestrel-releasing intrauterine systems [e.g., Mirena, Liletta]), OR
• B) An oral progesterone (e.g., norethindrone tablets), OR
• C) A depo-medroxyprogesterone injection.
• Note: An exception to the requirement for a trial of the above therapies can be made if the patient has previously used a gonadotropin-releasing hormone [GnRH] agonist (e.g., Lupron Depot) or antagonist (e.g., Orilissa).

Approval duration

1 year