Currentculinary health fundPolicy N/A

Gonadotropin-Releasing Hormone Agonists (Supprelin LA, Zoladex) — Coverage Criteria

Prior authorization and medical necessity criteria for coverage of histrelin (Supprelin LA) and goserelin (Zoladex) subcutaneous implants for specified indications; applies to providers prescribing these implants for Culinary Health Fund members.

Policy Summary

Payerculinary health fund

PolicyGonadotropin-Releasing Hormone Agonists (Supprelin LA, Zoladex) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateFeb 11, 2026

Key ActionObtain prior authorization and ensure prescription is by or in consultation with an appropriate specialist (e.g., endocrinologist, oncologist, or OB-GYN) as required by indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2products covered

MultipleFDA-approved indications

Prior authAuthorization

1 yrTypical approval length

Peripheral PPNon-covered condition

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Coverage and Medical Necessity Criteria

Supprelin LA - Initial/Other Uses

Covered when the following are met

Supprelin LA - FDA-approved indication: Central Precocious Puberty: Approve for 1 year.

Dosing: one 50 mg implant once every 12 months, inserted subcutaneously in the upper arm.

Supprelin LA - Other uses with supportive evidence: Gender dysphoric / gender-incongruent persons or persons undergoing gender reassignment: Approve for 1 year if prescribed by or in consultation with an endocrinologist or a physician who specializes in the treatment of transgender patients.

Dosing: one 50 mg implant once every 12 months, inserted subcutaneously in the upper arm.

Zoladex - Initial/Other Uses

Covered when ANY one of the following indication-specific criteria are met (see each node for required subcriteria)

Abnormal uterine bleeding (endometrial thinning before ablation): Approve for 2 months if BOTH A and B are met: A) Zoladex is used as an endometrial-thinning agent prior to endometrial ablation; AND B) prescribed by or in consultation with an obstetrician-gynecologist or a clinician who specializes in women's health.

Dosing: Zoladex 3.6 mg implant once every 28 days, inserted subcutaneously into the anterior abdominal wall.

Breast cancer: Approve for 1 year if prescribed by or in consultation with an oncologist.

Dosing options: A) Zoladex 3.6 mg every 28 days OR B) Zoladex 10.8 mg every 12 weeks, inserted subcutaneously into the anterior abdominal wall.

Endometriosis: Approve for 6 months if BOTH A and B are met: A) patient is ≥ 18 years of age; AND B) prescribed by or in consultation with an obstetrician-gynecologist or a clinician who specializes in women's health.

Dosing: Zoladex 3.6 mg implant once every 28 days, inserted subcutaneously into the anterior abdominal wall.

Prostate cancer: Approve for 1 year if prescribed by or in consultation with an oncologist.

Dosing options: A) Zoladex 3.6 mg every 28 days OR B) Zoladex 10.8 mg every 12 weeks, inserted subcutaneously into the anterior abdominal wall.

Gender dysphoria / transgender care (Zoladex): Approve for 1 year if prescribed by or in consultation with an endocrinologist or a clinician who specializes in the treatment of transgender patients.

Dosing: either Zoladex 3.6 mg every 28 days or Zoladex 10.8 mg every 12 weeks.

Peripheral (GnRH-independent) precocious puberty is caused by autonomous production of sex steroids outside the hypothalamic–pituitary–gonadal axis. Children with this form of precocious puberty do not respond to GnRH agonist therapy because the pathology driving early sexual development is independent of hypothalamic GnRH signaling; treatment must instead target the underlying source of excess sex steroids (for example, surgical removal of hCG-secreting tumors or medical therapy such as glucocorticoids for adrenal steroidogenesis defects).

Coverage is not recommended for indications or circumstances that are not explicitly listed in the Recommended Authorization Criteria. The criteria will be updated if new published data become available.

Use of Supprelin LA or Zoladex for peripheral (GnRH-independent) precocious puberty is not recommended and therefore is not covered. Children with this condition do not respond to GnRH agonists and require treatment directed at the cause of excess sex steroids.

Prescriber and Authorization Requirements

Prior Authorization

Prior Authorization Recommended

Prior authorization is recommended for medical benefit coverage of Supprelin LA and Zoladex. Approvals are issued for the durations noted in the FDA‑Approved Indications and dosing sections (when expressed in months, 1 month = 30 days). Extended approvals may be granted if the patient continues to meet the applicable Criteria and Dosing. Requests for doses outside the established dosing in this policy will be reviewed on a case‑by‑case basis by a clinician (e.g., Medical Director or Pharmacist). Because of the specialized evaluation and monitoring required for patients treated with Zoladex or Supprelin LA, these agents must be prescribed by or in consultation with a physician who specializes in the condition being treated.

Prior authorization recommended for medical benefit coverage of Supprelin LA and Zoladex.
All approvals provided for the duration noted in the indications; 1 month = 30 days when used.
Dose exceptions (requests for doses outside established dosing) considered case‑by‑case by clinician/Medical Director or Pharmacist.
Prescriber requirement: prescribed by or in consultation with a specialist appropriate to the condition (e.g., pediatric endocrinologist for central precocious puberty, oncologist for breast/prostate cancer, obstetrician‑gynecologist or women's health specialist for abnormal uterine bleeding/endometriosis).

Key Definitions

Central precocious puberty — definition and clinical context

DefinitionCentral precocious puberty (also called gonadotropin-dependent precocious puberty) — early maturation of the hypothalamic-pituitary-gonadal axis treated with GnRH agonists.

Typical presentationOnset of secondary sexual characteristics earlier than expected for age due to central activation of the HPG axis.

Recommended treatmentGnRH agonists (including histrelin implants such as Supprelin LA) are the standard of care for central precocious puberty.

Approval note (policy)Supprelin LA: approve for 1 year for central precocious puberty; dosing — one 50 mg implant every 12 months, inserted subcutaneously in the upper arm.

Pubertal suppression for gender-dysphoria — initiation and reversibility

Definition

Clinical Background

Supprelin LA (histrelin) and Zoladex (goserelin) are gonadotropin-releasing hormone (GnRH) agonist implants that act by suppressing the hypothalamic–pituitary–gonadal axis. By providing sustained GnRH agonism, these implants down-regulate pituitary gonadotropin release and subsequently reduce sex-steroid production from the gonads; this mechanism underlies their use for GnRH-dependent conditions such as central precocious puberty and for various oncologic and gynecologic indications. Because peripheral (GnRH-independent) sources of sex steroids bypass this axis, GnRH agonist implants are ineffective for those causes.

Policy Summary

Payerculinary health fund

PolicyGonadotropin-Releasing Hormone Agonists (Supprelin LA, Zoladex) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateFeb 11, 2026

Key ActionObtain prior authorization and ensure prescription is by or in consultation with an appropriate specialist (e.g., endocrinologist, oncologist, or OB-GYN) as required by indication.

SourceLink

On This Page

Documentation Required

Dose Exceptions Reviewed Case‑by‑Case

Requests for dosing or regimens not described in the policy (including doses, frequency, or duration outside the established dosing) will be evaluated individually by clinical staff. Documentation supporting the medical necessity of the requested deviation (clinical rationale, prior treatment history, relevant labs/imaging) should be submitted to facilitate review.

Documentation Required

Prescriber Specialty / Consultation Required

The medication must be prescribed by, or in consultation with, a physician who specializes in the condition being treated. Examples include: pediatric endocrinologists for central precocious puberty; oncologists for breast or prostate cancer; obstetrician‑gynecologists or clinicians specializing in women's health for abnormal uterine bleeding and endometriosis. Authorization may be denied if the prescriber specialty requirement or documentation of specialist consultation is not met.

Denial Risk

Denial Triggers

Coverage is not recommended for peripheral (GnRH‑independent) precocious puberty and for any conditions not listed in the Recommended Authorization Criteria. Requests for indications outside the policy's recommended criteria are subject to denial.

Peripheral Precocious Puberty (GnRH‑independent) — not recommended for approval.
Any circumstance not listed in the Recommended Authorization Criteria may be denied.

Pubertal suppression for gender-dysphoria — use of GnRH agonists to suppress physical changes of puberty (typically in adolescents undergoing gender transition).

Typical initiation criteriaTypically initiated after the adolescent first exhibits physical changes of puberty (Tanner stage G2/B2).

ReversibilityEffects are reversible — pubertal suppression can be discontinued and spontaneous pubertal development has been shown to resume.

Clinical use noteGnRH analogs may also be used later in puberty to allow for lower doses of cross-sex hormones and are used in adolescents and some adults during transition.