Lupron Depot — Medical Mutual
Head and Neck Cancer – Salivary Gland Tumors
Initial criteria
- Approve Lupron Depot 3.75 mg, 7.5 mg, 11.25 mg, or 22.5 mg for 1 year if:
- A) Patient has recurrent, unresectable, or metastatic disease
- B) Patient has androgen receptor (AR)-positive disease
- C) Prescribed by or in consultation with an oncologist
Approval duration
1 year