Policy: GnRH Agents
Policy Number: 9.703 v 1.1
Last Update: 2021-02-24
Issued in: Massachusetts

This policy applies to Medicaid

Youth Services:

Preferred Agents:

Leuprolide, Lupron (leuprolide), Trelstar (triptorelin), Zoladex (goserelin) Documentation of the one of following:

1. Member is less than 18 years of age; AND

• A diagnosis of gender dysphoria/gender incongruent; AND
• Have experienced puberty to at least Tanner stage 2; AND
• Absence of psychiatric comorbidity that interferes with the diagnostic work-up or treatment; AND
• Have adequate psychological and social support during treatment; AND
• Demonstrate knowledge and understanding of the expected outcomes of GnRH analog treatment;
• OR
• Member age is 18 years or older; AND
• A diagnosis of gender dysphoria/gender incongruent; AND
• Capacity to make a well-informed decision and consent to treatment; AND
• Medical or mental issues if present are well-controlled; AND d. The regimen is a trans-feminine regimen (male to female); AND
• Failure to achieve physiologic hormone levels or an intolerance with use of oral estrogens and spironolactone