Lupron Depot — Medical Mutual
Prophylaxis or Treatment of Uterine Bleeding or Menstrual Suppression in Patients with Hematologic Malignancy, or, Undergoing Cancer Treatment, or Prior to Bone Marrow/Stem Cell Transplantation
Initial criteria
- Approve Lupron Depot 3.75 mg or 11.25 mg for 1 year if prescribed by or in consultation with a hematologist or oncologist
Approval duration
1 year