Policy: Gonadotropin-Releasing Hormone Analogs and Antagonists
Policy Number: 0501
Last Update: 2021-07-21

This policy applies to Medicaid

Youth Services:

Aetna considers Lupron Depot, Lupron Depot-PED, Leuprolide acetate (Eligard, Fensolvi), Goserelin (Zoladex), Vantas, Supprelin LA, and Triptorelin (Trelstar; Triptodur) medically necessary for the following indications: ... for pubertal suppression in preparation for gender reassignment in an adolescent member when all of the following criteria are met: 1. The member has a diagnosis of gender dysphoria; and 2. The member has reached Tanner stage 2 of puberty.