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Coverage / Medical Mutual / Lupron Depot / Other NCCN category 1, 2A, or 2B recommended indications

Lupron Depot — Medical Mutual

Other NCCN category 1, 2A, or 2B recommended indications

Initial criteria

Prescriber will provide specific diagnosis for documentation. Approve.

Provenance

View official policy PDF

Plan: Medical Mutual
Drug: Lupron Depot
Indication: Other NCCN category 1, 2A, or 2B recommended indications
Last seen: 2025-10-10
Hash: 47c6013ff00a…

Disclaimer: Educational only. Coverage varies by employer group and formulary. Always verify with the plan.

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Disclaimer: Educational use only. Coverage varies by employer group and formulary. Always verify with the plan.

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