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Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg)
BCBS Tennessee·TN · OB-GYN, Oncology, Endocrinology +4 more·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
This is a NEW medical policy for Leuprolide Suspension (Lupron Depot) effective 12/1/26 that establishes coverage criteria, prior authorization requirements, and treatment duration limits across multiple indications including endometriosis, uterine fibroids, cancers, gender dysphoria, and acute porphyria. The policy requires documentation of hormone receptor status for certain cancer indications and mandates specialized provider consultation for gender dysphoria and porphyria cases.
Action Required
By November 1, 2026: Billing and clinical teams must implement this new policy across all applicable workflows. (1) Configure billing system to require prior authorization for all Leuprolide/Lupron Depot claims with indication-specific authorization periods (6 months for endometriosis, 3 months for fibroids, 12 months for cancers/dysphoria/porphyria). (2) Create or update prior auth request forms to capture required documentation: AR-positive and HR-positive status for breast/ovarian/salivary cancers; diagnosis confirmation for all indications. (3) Update encounter templates and provider workflows to document: member age/Tanner stage (gender dysphoria), BMD status (endometriosis retreatment), anemia status (fibroids), comorbidity control, fertility preservation counseling, and contraindication/side effect education. (4) Establish prescriber specialty verification rules—require consultation with pediatric endocrinologist/family medicine/OB-GYN with mental health collaboration for gender dysphoria patients under 18; porphyria specialist for acute porphyria cases. (5) Configure system to enforce lifetime maximums: 12 months total for endometriosis, 6 months total for fibroids. (6) Providers and billing team must communicate these requirements immediately to prevent claim denials after 12/1/26. Failure to obtain prior authorization or meet documentation requirements will result in claim denials.