Policy: Leuprolide Acetate (Eligard, Lupaneta Pack, Lupron Depot, Lupron Depot-Ped)
Policy Number: CP.PHAR.173
Last Update: 2020-08
Issued in: Ohio

This policy applies to Medicaid

Youth Services:

1. Diagnosis of gender dysphoria;
2. Request is not for Lupaneta Pack;
3. Prescribed by or in consultation with an endocrinologist and an expert in gender dysphoria and transgender medicine (e.g., mental health professional such as psychologist, psychiatrist);
4. Age and pubertal development - meets (a or b):
   1. Member has reached or passed through Tanner Stage 2* and is < 18 years of age; ______________*Age ranges approximating Tanner Stage 2 pubertal development extend from 8 to 13 years of age in girls and 9 to 14 years of age in boys.
   2. Member is ≥ 18 years of age and has failed to achieve physiologic hormone levels with gender-affirming hormonal therapy (e.g., estrogen, testosterone) unless contraindicated or clinically significant adverse effects are experienced;
5. Member demonstrates understanding of expected GnRH analogue treatment outcomes and has given consent for such treatment;
6. If member has a psychiatric comorbidity, member is followed by mental health provider;
7. Psychosocial support will be provided during treatment;
8. Dose is within FDA maximum limit for any FDA-approved indication or is supported by practice guidelines or peer-reviewed literature for the relevant off-label use (prescriber must submit supporting evidence).