Policy: Gonadotropin-Releasing Hormone Agonists
Last Update: 2021-11-01
Next Update: 2022-03
Issued in: New York

Youth Services:

Coverage for Lupron Depot®/Lupron Depot Ped® is provided for treatment of the following conditions:

• Gender dysphoria
• The diagnosis of gender dysphoria and the referral for hormone therapy have been made by a mental health professional in accordance with the WPATH criteria AND o The patient must be followed by an endocrinologist AND
• if used for suppression of puberty, therapy should not be started earlier than Tanner stage 2.