CommercialPrior AuthHigh impact
Leuprolide Acetate Depot Suspension [Lupron Depot (1 month) 7.5mg, Lupron Depot (3 month) 22.5mg, Lupron Depot (4-Month) 30 mg, Lupron Depot (6-Month) 45 mg]; Leuprolide acetate depot (3-month 22.5 mg); Lutrate Depot® (3-month 22.5 mg)
BCBS Tennessee·TN · Oncology, Urology, OB-GYN +5 more·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
BlueCross BlueShield of Tennessee is establishing a new medical policy for Leuprolide Acetate Depot (Lupron Depot and Lutrate Depot) covering four FDA-approved indications: advanced prostate cancer, ovarian cancer (malignant sex cord-stromal tumors), breast cancer (premenopausal with hormone-receptor positive status), and gender dysphoria. All covered uses require prior authorization with specific approval criteria, and the policy includes detailed requirements for gender dysphoria treatment involving age restrictions, provider specialization, and documented informed consent. This policy will supersede any existing guidance effective December 1, 2026.
Action Required
By November 15, 2026: Billing and prior authorization teams must implement this new Leuprolide Acetate policy in the BCBS Tennessee billing system and prior auth software. Update prior auth requirements to mandate documentation of: (1) diagnosis confirmation for prostate cancer, ovarian cancer, or breast cancer; (2) hormone receptor (HR) positive status for breast cancer; (3) gender dysphoria diagnosis with specialized provider consultation and mental health collaboration for members under 18; (4) Tanner stage documentation for gender dysphoria claims; (5) proof of informed consent regarding fertility preservation and side effects. Configure system to auto-approve 12-month authorizations for initial treatment and continuation of therapy when clinical benefit is documented (e.g., serum testosterone <50 ng/dL for prostate cancer). For breast cancer, limit total authorization to 5 years maximum. Flag any gender dysphoria claims for members under 18 for manual review to verify compliance with state regulatory guidelines and age restrictions. Update encounter forms and prior auth checklists to capture all required documentation. Claims without proper prior auth or missing required documentation will be denied. Train all billing staff and providers on new requirements before December 1, 2026.