Effective immediately, Harvard Pilgrim will provide reimbursement for a higher maximum dosage of Lupron Depot for commercial members being treated for breast cancer. Reimbursement will be provided for up to 7.5 milligrams of Lupron monthly, or 22.5 milligrams for 3 months, administered as a single injection for patients with breast cancer.
For all other indications, the allowed maximum dosage has not been changed. Prior authorization is required for coverage of Lupron Depot through CVS Health—NovoLogix, which oversees our prior authorization program for medical drugs. To request authorization for Lupron Depot, please contact CVS Health–NovoLogix via phone (844-387-1435) or fax (844-851-0882). For complete information, please refer to our updated Lupron Depot Medical Review Criteria and the associated prior authorization request form.