CommercialPrior AuthMedium impact
Histrelin Acetate (Supprelin® LA)
BCBS Tennessee·TN · Pediatrics, Endocrinology, OB-GYN +2 more·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
This is a new BlueCross BlueShield of Tennessee medical policy for Histrelin Acetate (Supprelin® LA) covering four indications: central precocious puberty (FDA-approved), gender dysphoria, preservation of ovarian function, and prevention of recurrent menstrual-related attacks in acute porphyria. The policy establishes coverage criteria, prior authorization requirements (12 months for CPP/gender dysphoria/porphyria; 3 months for ovarian preservation), specific documentation requirements, and prescriber specialty mandates. Implementation is prohibited until December 1, 2026.
Action Required
By November 15, 2026: Billing and prior authorization teams must prepare for policy implementation. (1) Configure prior authorization system to require 12-month authorizations for CPP, gender dysphoria, and acute porphyria cases; 3-month authorizations for ovarian preservation. (2) Update prior auth request forms to require: CPP cases—GnRH agonist stimulation test results or third-generation LH assay documentation plus bone age assessment; gender dysphoria cases—confirmation of Tanner stage 2+, comorbidity control status, fertility preservation counseling documentation, and mental health provider collaboration (for members <18); porphyria cases—physician experience documentation. (3) Create prescriber validation rules: gender dysphoria requires pediatric endocrinologist, family medicine, internal medicine, or OB-GYN with mental health collaboration (for <18); porphyria requires porphyria-experienced provider. (4) Configure system alerts for age restrictions per Tennessee state law for gender dysphoria cases. (5) Train prior auth staff and providers on documentation requirements before December 1, 2026. Claims submitted without required prior authorization or documentation will be denied. Effective Date: 12/01/2026.