Policy: Gonadotropin Releasing Hormones (GnRHs) Analogs
Policy Number: I-16-020
Last Update: 2020-07-06
Issued in: West Virginia

Youth Services:

The use of histrelin acetate (Supprelin LA, Vantas), leuprolide acetate (Lupron Depot, Lupron Depot-Ped Fensolvi), or triptorelin (Triptodur, Trelstar) may be considered medically necessary for puberty suppression in individuals with gender dysphoria when ALL of the following criteria are met: