Policy: Gonadotropin Releasing Hormone Analogs and Antagonists
Policy Number: 09-J0000-48
Last Update: 2021-03-15
Issued in: Florida

Youth Services:

Leuprolide acetate suspension for intramuscular depot administration (Lupron Depot 1-Month, Lupron Depot 3-Month, Lupron Depot 4- Month, Lupron Depot 6- Month)

1. Gender dysphoria [previously known as gender identity disorder (GID)] in adults meeting ALL of the following criteria:
   1. The member is 18 years of age or older
   2. The diagnosis of gender dysphoria (per DSM-V criteria for adolescents and adults) has been confirmed by a licensed mental health professional – documentation must be submitted
   3. Treatment will be used to reduce the member’s levels of endogenous hormones (e.g., testosterone or estrogen)
   4. The member is determined, by a licensed mental health professional, to have the capacity to make fully informed decisions and provide consent for treatment
   5. Any significant medical or mental health concerns (if present) are