Leuprolide acetate (Fensolvi®, Lupron Depot-PED®, Lupron Depot®) Non-oncology

Covers non‑oncology uses of leuprolide acetate: Fensolvi and Lupron Depot‑PED for central precocious puberty (CPP) and selected gender‑affirming care, and Lupron Depot for endometriosis, uterine leiomyomata (preoperative anemia with iron), abnormal uterine bleeding, premenstrual disorders, and selected gender‑affirming care; oncology indications are outside this policy. Key requirements: document diagnosis and patient age (Fensolvi ≥2 years; PMD ≥18 years), prior therapy trials or contraindications for endometriosis and PMD (e.g., contraceptives/progestins/GnRH agents for endometriosis; SSRI or combined OCP for PMD), prescriber or consultation by an endocrinologist or transgender‑care specialist for gender‑related uses, and comply with approval durations (12 months for Fensolvi and Lupron Depot‑PED; Lupron Depot: 3 months for fibroids, 6 months for AUB, 12 months for other indications).

"For Premenstrual Disorders (Lupron Depot): patient must have severe, refractory premenstrual symptoms."