CurrentBlue Shield of CaliforniaPolicy N/A

Degarelix (Firmagon) Coverage

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This commercial medical benefit drug policy governs coverage and prior-authorization requirements for degarelix (Firmagon), including its use for gender dysphoria in adolescents. It also directs providers to submit clinical documentation and use the assigned billing codes.

Policy Summary

PayerBlue Shield of California

PolicyDegarelix (Firmagon) Coverage

Policy CodePolicy N/A

Change TypeAdministrative delegation change

Effective DateApril 1, 2026

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionFor applicable PPO, Direct Contract HMO, ASO, and Shared Advantage products, submit requests through Evolent's CarePro Provider Portal.

SourceLink

POLICY UPDATE CHANGES

Effective April 1, 2026, Evolent will make medical necessity determinations for oncology-related indications.

J9155Assigned HCPCS code for degarelix 1 mg

240 mgMaximum first dose

80 mg/23 daysSubsequent subcutaneous dosing interval

4Listed ICD-10 diagnosis codes

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CurrentBlue Shield of CaliforniaPolicy N/A

Degarelix (Firmagon) Coverage

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Sign up for all blue_shield_of_california policy alerts

Know when blue_shield_of_california releases new policies or updates existing guidance.

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Policy Summary

PayerBlue Shield of California

PolicyDegarelix (Firmagon) Coverage

Policy CodePolicy N/A

Change TypeAdministrative delegation change

Effective DateApril 1, 2026

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionFor applicable PPO, Direct Contract HMO, ASO, and Shared Advantage products, submit requests through Evolent's CarePro Provider Portal.

SourceLink

POLICY UPDATE CHANGES

Effective April 1, 2026, Evolent will make medical necessity determinations for oncology-related indications.

J9155Assigned HCPCS code for degarelix 1 mg

240 mgMaximum first dose

80 mg/23 daysSubsequent subcutaneous dosing interval

4Listed ICD-10 diagnosis codes

Coverage Criteria

Gender Dysphoria in Adolescents

Covered without prior authorization or preservice review when ALL of the following are met:

Gender dysphoria in adolescents criteria

Indication and diagnosis
- The member is being treated for gender dysphoria in adolescents.
- ONE of the following ICD-10 codes
  - ICD-10 F64.0 — Gender identity disorder in adolescence and adulthood
  - ICD-10 F64.1 — Dual role transvestism
  - ICD-10 F64.2 — Gender identity disorder of childhood
  - ICD-10 F64.9 — Gender identity disorder, unspecified
Covered dosing
- The first dose does not exceed 240 mg.First dose ≤ 240 mg
- Subsequent dosing is 80 mg subcutaneously no sooner than every 23 days.80 mg subcutaneously; interval ≥ 23 days

Conditions not listed in this policy are not automatically eligible under these coverage criteria. Such conditions require a review to confirm medical necessity.

For off-label use, the criteria outlined in California Health and Safety Code section 1367.21 must be met.

Coding and Dose Parameters

Covered HCPCS CodesHCPCSCovered

J9155

Injection, degarelix, 1 mg

Covered ICD-10 CodesICD-10Covered

F64.0	Gender identity disorder in adolescence and adulthood
F64.1	Dual role transvestism
F64.2	Gender identity disorder of childhood
F64.9	Gender identity disorder, unspecified

First-Dose Limit

Medicationdegarelix (Firmagon)

Dose stageFirst dose

Maximum permitted doseNot to exceed 240 mg

Subsequent-Dose Limit

Medicationdegarelix (Firmagon)

Covered dose80 mg subcutaneously

Minimum dosing intervalNo sooner than every 23 days

Provider Submission Requirements

Prior Authorization

Prior Authorization Depends on All Criteria

Prior Authorization/Preservice review is not required only when all stated parameters are met for the listed indication, including the applicable diagnosis and dosing limits. If any parameter is not met, Prior Authorization/Preservice is required.

Note

Submit Applicable Oncology Requests Through Evolent

For oncology-related requests under applicable products, submit the request directly through Evolent’s CarePro Provider Portal. This applies to PPO, Direct Contract HMO, and, when applicable, ASO and Shared Advantage products.

Documentation Required

Drug Background

Degarelix (Firmagon) is a gonadotropin-releasing hormone (GnRH), also called luteinizing hormone-releasing hormone (LHRH), antagonist. It is classified as a hormonal agent that suppresses adrenal or pituitary activity. The policy addresses its coverage criteria for gender dysphoria in adolescents.

Terminology

GnRH/LHRH Antagonist

TermGnRH antagonist

Full nameGonadotropin-releasing hormone antagonist

SynonymLHRH antagonist

Alternative full nameLuteinizing hormone-releasing hormone antagonist

Initial Therapy

Initial Therapy Criteria

For initial therapy, ALL of the following are required:

Initial degarelix therapy

The member is being treated for gender dysphoria in adolescents.
ONE of the following qualifying ICD-10 codes
- F64.0 — Gender identity disorder in adolescence and adulthood
- F64.1 — Dual role transvestism
- F64.2 — Gender identity disorder of childhood

Maintenance Dosing

After the first dose, covered maintenance dosing requires ALL of the following:

Subsequent degarelix dosing

Administer 80 mg subcutaneously.80 mg
Administer the dose no sooner than every 23 days.Interval ≥ 23 days

Quantity and Frequency Limits

First-Dose Quantity Limit

Medicationdegarelix (Firmagon)

Dose stageFirst dose

Maximum quantity limitNot to exceed 240 mg

Subsequent-Dose Quantity Limit

Medicationdegarelix (Firmagon)

Subsequent quantity80 mg

RouteSubcutaneously

Minimum frequency limit

Permitted Administration Settings

Note

Office administration

Office administration is listed as an eligible place of service for degarelix (Firmagon).

Note

Hospital outpatient administration

Outpatient facility infusion administration is listed as an eligible place of service for degarelix (Firmagon).

Note

Infusion center administration

Infusion center administration is listed as an eligible place of service for degarelix (Firmagon).