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  • Current: Blue Cross and Blue Shield of Florida - Gonadotropin Releasing Hormone Analogs and Antagonists

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Blue Cross and Blue Shield of Florida

Gonadotropin Releasing Hormone Analogs and Antagonists


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

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Updated on Nov 23, 2021

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