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BCBS TennesseeAll Plans · Prior Auth · Medical Policy · TN · OB-GYN, Oncology, Endocrinology +3 moreMedium impact

Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg)

Effective date
Dec 1, 2026
Identified
Sep 10, 2026

Summary

Lupron Depot 3.75 mg and Lupron Depot 3-Month 11.25 mg are covered for endometriosis, including pain relief and reduction of endometriotic lesions, and for preoperative hematologic improvement in women with anemia caused by fibroids when used with iron therapy, when the approval criteria are met. Covered compendial uses include breast cancer, ovarian cancer, salivary gland tumors, gender dysphoria, preservation of ovarian function, prevention of recurrent menstrual related attacks in acute porphyria, and uterine sarcoma. The total duration of therapy plus add-back therapy for endometriosis should not exceed 12 months due to concerns about bone mineral density, and the medication is not indicated for combination use with norethindrone acetate add-back therapy for anemia caused by heavy menstrual bleeding due to fibroids.

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What to do

Action · 8 steps
01Future transition 2026-12-01: Where applicable, submit test results confirming androgen receptor (AR) positive status and hormone receptor (HR) positive status to start prior authorization review.
02For endometriosis, the initial authorization is up to 6 months (one treatment course).
03For retreatment of endometriosis, authorization of up to 6 months (for a lifetime maximum of 12 months total) requires that the member has had a recurrence of symptoms and has a bone mineral density within normal limits.
04For uterine fibroids, the initial authorization is up to 3 months when the member has anemia due to uterine leiomyomata or when Lupron Depot will be used prior to surgery, and continuation is up to 3 months (for a lifetime maximum of 6 months total) under the same criteria.
05Authorization is up to 12 months for breast cancer, ovarian cancer, salivary gland tumor, uterine sarcoma and porphyria-related attacks, and up to 3 months for preservation of ovarian function in a premenopausal member undergoing chemotherapy.
06For gender dysphoria, the medication must be prescribed by or in consultation with a provider specialized in the care of transgender youth, such as a pediatric endocrinologist, family or internal medicine physician, or obstetrician-gynecologist, who has collaborated care with a mental health provider for members under 18, and age restrictions may apply under state regulatory guidelines.
07For acute porphyria, the medication must be prescribed by or in consultation with a provider experienced in the management of porphyrias.
08All members, including new members, requesting continuation must meet all requirements in the coverage criteria section.

Original notice

Leuprolide Suspension (Lupron Depot®, Leuprolide Acetate Depot 1-Month 3.75mg, 3-Month 11.25 mg)
bcbst.com · Always check the source before changing claims.
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BCBS Tennessee policiesTN policy changesOB-GYNOncologyEndocrinologyPediatricsFamily MedicineInternal Medicine

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