Prior Authorization Required

Prior authorization is required for requests for leuprolide products. Approval criteria enumerate diagnosis-specific, prescriber, dosing, and prior-failure requirements as applicable. Requests for continued therapy also require prior authorization and must meet the indication-specific continued therapy criteria.

• Prior authorization required for initial and continued therapy.
• Commercial approval durations and certain concurrent therapy requirements updated per most recent reviews (see policy history).
• HCPCS code J1954 added to coding appendix for 4Q 2024 updates.

Lupron Depot step / Redirection Risk for Prostate Cancer

For requests submitted through the pharmacy benefit for Lupron Depot where the indication is prostate cancer, prescribers must document prior failure of Eligard (or provide rationale why Eligard is contraindicated or caused clinically significant adverse effects) before Lupron Depot will be approved, unless the request is for treatment in a state with regulations prohibiting redirection (see Appendix F).

• Lupron Depot pharmacy‑benefit requests for prostate cancer may be redirected to Eligard unless contraindicated or adverse effects documented.
• Appendix F lists states where redirection/step therapy for oncology is prohibited.

Step Therapy / Redirection for Oncology

Requests for oncology indications may be subject to step therapy or redirection to an alternative product (for example, redirection of Lupron Depot requests to Eligard through the pharmacy benefit) except where prohibited by state regulations listed in Appendix F. Providers should be aware that redirection is distinct from medical necessity review and that exceptions must be documented when applicable.

• Step therapy/redirection may be applied for prostate cancer except in states listed in Appendix F.
• Redirection does not replace medical necessity review; provide clinical justification for exceptions.

Supportive Documentation Required

Providers must submit supporting documentation (office chart notes, lab results, prior medication records, prescribing rationale, and any evidence of contraindication or adverse reaction) demonstrating the member meets all approval criteria. Failure to provide sufficient documentation may result in denial.

• Include documentation showing member is currently receiving the medication (or received it for at least 30 days) and is responding positively when requesting continued therapy.
• If requesting an exception to step therapy (e.g., avoiding redirection to Eligard), include documentation of contraindication or clinically significant adverse effects to the alternative.

Lupron Depot (pharmacy benefit) Prior Failure Requirement

When requesting Lupron Depot through the pharmacy benefit for prostate cancer, the prescriber must attest that Eligard was tried and failed (or provide documentation of contraindication/adverse effects) unless the request originates from a state listed in Appendix F that prohibits redirection. This requirement applies to initial requests submitted via the pharmacy benefit.

• Document prior trial and failure of Eligard or document contraindication/adverse event.
• If the state is listed in Appendix F, note the state and reference the applicable regulation to avoid redirection.