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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsClover Health Eligard Prior Auth Coverage | OpenPa…
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    CurrentClover HealthPolicy 3959-A

    Jurisdiction Specific Medicare Part B Eligard

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    This policy governs prior authorization and coverage of Eligard under Medicare Part B for specified oncologic, gynecologic, and gender dysphoria indications in Medicare Administrative Contractor Jurisdictions 06 and K.

    Policy Summary
    PayerClover Health
    PolicyJurisdiction Specific Medicare Part B Eligard
    Policy CodePolicy 3959-A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit supporting evidence from Medicare-approved compendia for indications other than those specifically listed.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    10 statesJurisdiction-specific states covered
    6Listed covered indications
    12 monthsProstate cancer authorization
    6 monthsUterine leiomyoma authorization
    12 monthsOther listed indications authorization

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Covered Indications

    Prostate Cancer

    Covered when the requested use is treatment of prostate cancer.

    Prostate cancer: The requested drug will be used to treat prostate cancer.

    Authorization may be granted for 12 months.

    Carcinoma of the Breast

    Covered when both criteria are met.

    Carcinoma of the breast

    • Palliative treatment: The requested drug will be used as palliative treatment.
    • Menopausal status: The member is premenopausal or perimenopausal.premenopausal or perimenopausal

    Salivary Gland Tumors

    Covered when the requested use is treatment of salivary gland tumors.

    Salivary gland tumors: The requested drug will be used to treat salivary gland tumors.

    Authorization may be granted for 12 months.

    Ovarian Cancer

    Covered when the requested use is treatment of ovarian cancer.

    Ovarian cancer: The requested drug will be used to treat ovarian cancer.

    Authorization may be granted for 12 months.

    Uterine Leiomyoma

    Covered when the requested use is treatment of uterine leiomyoma.

    Uterine leiomyoma: The requested drug will be used to treat uterine leiomyoma.

    Authorization may be granted for 6 months.

    Gender Dysphoria

    Covered when the requested use is treatment of gender dysphoria.

    Gender dysphoria: The requested drug will be used to treat gender dysphoria.

    Authorization may be granted for 12 months.

    All Other Indications

    Covered when the requested use is an approvable indication listed in LCA A52453.

    Other approvable indications: The requested drug will be used for an approvable indication listed in LCA A52453.listed in LCA A52453

    Authorization may be granted for 12 months.

    Authorization and Submission Requirements

    Prior Authorization

    Prostate cancer authorization

    Authorization of 12 months may be granted for treatment of prostate cancer.

    Prior Authorization

    Breast carcinoma authorization

    Authorization of 12 months may be granted for treatment of carcinoma of the breast when both requirements are met.

    • The requested drug will be used as palliative treatment.
    • The member is premenopausal or perimenopausal.
    Prior Authorization

    Salivary gland tumor authorization

    Authorization of 12 months may be granted for treatment of salivary gland tumors.

    Eligard Policy Background

    Eligard contains leuprolide acetate and is evaluated under this policy for prostate cancer, carcinoma of the breast, salivary gland tumors, ovarian cancer, uterine leiomyoma, and gender dysphoria. Coverage is available when applicable approval criteria are met and the member has no exclusions to the prescribed therapy. Other approvable indications listed in LCA A52453 may be assessed individually with supporting evidence from Medicare-approved compendia.

    Policy Summary
    PayerClover Health
    PolicyJurisdiction Specific Medicare Part B Eligard
    Policy CodePolicy 3959-A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit supporting evidence from Medicare-approved compendia for indications other than those specifically listed.
    SourceLink
    On This Page
    Covered IndicationsAuthorization and Submission RequirementsEligard Policy Background
    Prior Authorization

    Ovarian cancer authorization

    Authorization of 12 months may be granted for treatment of ovarian cancer.

    Prior Authorization

    Uterine leiomyoma authorization

    Authorization of 6 months may be granted for treatment of uterine leiomyoma.

    Prior Authorization

    Gender dysphoria authorization

    Authorization of 12 months may be granted for treatment of gender dysphoria.

    Prior Authorization

    Other approvable indications

    Authorization of 12 months may be granted for treatment of other approvable indications listed in LCA A52453.

    Documentation Required

    Submit compendial support

    For indications other than those specifically listed, submit supporting evidence from Medicare-approved compendia with the authorization request.

    Denial Risk

    Meet all approval requirements

    Coverage requires that all applicable approval criteria are met and that the member has no exclusions to the prescribed therapy.

    • Confirm that the requested use satisfies the applicable indication-specific criteria.
    • Verify that the member has no exclusions to the prescribed therapy.
    Denial Risk

    Unlisted or unsupported indication

    Indications not listed in the policy are assessed on an individual basis and require supporting evidence from Medicare-approved compendia. Coverage is limited to other approvable indications listed in LCA A52453.