Leuprolide Acetate Depot Suspension (Lupron Depot-Ped®)

By September 30, 2026: Billing and clinical teams must implement prior authorization processes for all Lupron Depot-Ped® prescriptions. (1) Update billing system to require prior authorization for both CPP and gender dysphoria indications, with authorization limited to 12-month periods. (2) Create PA requirement documentation templates that capture: for CPP—laboratory evidence (GnRH agonist test response or third-generation LH assay results), bone age assessment, age at symptom onset, and pathologic cause assessment; for gender dysphoria—diagnosis confirmation, Tanner stage 2+ documentation, comorbidity status, informed consent records, contraindication/side effect education documentation, and fertility preservation counseling records. (3) Providers must verify prescriber specialty for gender dysphoria cases (pediatric endocrinologist, family/internal medicine, or OB-GYN with mental health collaboration documented for members under 18); Route prescriptions lacking required specialization to denial. (4) Implement age-based approval restrictions per Tennessee state regulatory guidelines for gender dysphoria cases. (5) Configure system to enforce continuation criteria: CPP patients must be female <12 years old or male <13 years old with no treatment failure signs; gender dysphoria continuation requires diagnosis confirmation and concurrent gender-affirming hormone therapy documentation. (6) Front-desk staff must screen all Lupron Depot-Ped® prescriptions to determine indication and route to appropriate PA pathway. Failure to obtain prior authorization or submit required documentation will result in claim denials. Note: Do not implement changes before 9/30/2026 per policy header.