Lupron Depot — Highmark
gender identity disorder
Initial criteria
- Diagnosis of gender dysphoria or gender identity disorder (ICD-10: F64)
- If member is 15 years of age or younger, the drug is prescribed by a clinician competent in the evaluation and induction of pubertal development
Reauthorization criteria
- Prescriber attests that the member has experienced a positive clinical response to therapy
- Member requires continued therapy with the requested product
Approval duration
12 months