Lupron Depot — Medical Mutual
Endometriosis
Preferred products
- combination oral contraceptives
- Mirena
- Liletta
- norethindrone tablets
- depo-medroxyprogesterone injection
Initial criteria
- Approve Lupron Depot (3.75 mg or 11.25 mg) for 1 year if the 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, unless contraindicated
- NOTE: An exception can be made if the patient has previously used a GnRH agonist (e.g., Lupron Depot) or antagonist (e.g., Orilissa)
Approval duration
1 year