Lupron Depot — Medical Mutual
Premenstrual Disorders (Premenstrual Syndrome and Premenstrual Dysphoric Disorder)
Preferred products
- SSRIs
- combined oral contraceptive
Initial criteria
- Approve Lupron Depot 3.75 mg or 11.25 mg for 1 year if ALL are met:
- A) Patient age ≥ 18 years
- B) Patient has severe, refractory premenstrual symptoms per prescriber
- C) Patient has tried one of the following therapies: i) a SSRI (e.g., citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) OR ii) a combined oral contraceptive
Approval duration
1 year