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  • Current: Boston Medical Center Health NetPlan / Well Sense - GnRH Agents

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Boston Medical Center HealthNet Plan / Well Sense

GnRH Agents


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

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Updated on Nov 23, 2021

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