Initial Approval Criteria
A. Prostate Cancer (must meet all):
1. Diagnosis of prostate cancer;
2. Request is for leuprolide acetate injection, Eligard, or Lupron Depot (7.5 mg, 22.5mg, 30 mg, 45 mg);
3. Prescribed by or in consultation with an oncologist or urologist;
4. Age ≥ 18 years;
5. Request meets one of the following (a, b, or c):*
a. Leuprolide acetate injection (SC): Dose does not exceed 1 mg per day;
b. Eligard (SC)/Lupron Depot (IM): Dose does not exceed 7.5 mg per month, 22.5mg per 3 months, 30 mg per 4 months, 45 mg per 6 months;
c. Dose is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).
*Prescribed regimen must be FDA-approved or recommended by NCCN
DOSAGE/ADMINISTRATION
Advanced Prostate Cancer
Lupron: 7.5 mg IM monthly, 22.5 mg IM every 3 months, 30 mg IM every 4 months, or 45 mg IM every 6 months
Eligard: 7.5 mg SC monthly, 22.5 mg SC every 3 months, 30 mg SC every 4 months, 45 mg SC every 6 months
Lutrate Depot: 22.5 mg SC every 3 months
Leuprolide acetate: 1 mg/0.2 mL/day SC
Camcevi: 42 mg SC every 6 months
