Pituitary suppressive agents (LHRH) prior authorization
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Prior authorization form and requirements for pituitary suppressive LHRH agents (for indications including central precocious puberty, gender dysphoria, endometriosis, preservation of ovarian function, and specified oral GnRH antagonist combination products); intended for prescribers seeking coverage.
No material clinical or coverage changes in this revision.
Coverage Criteria and Indication-Specific Requirements
Central Precocious Puberty criteria
Covered when ALL applicable indication-specific criteria on the form are met and documentation is submitted:
Document specialist consult, patient sex, age, and onset timing; submit DX code and supporting documentation.
Gender dysphoria criteria
Covered when ALL the following are met for gender dysphoria:
Document provider experience/training and adherence to WPATH or equivalent standards.
Endometriosis criteria
Covered when ALL the following are met for endometriosis:
Submit laparoscopy report and documentation of NSAID and oral contraceptive trials or stated contraindications/intolerances.
Preservation of ovarian function criteria
Covered when ALL the following are met for preservation of ovarian function:
Document the cancer treatment and provide supporting citation(s) to NCCN guidelines or peer-reviewed literature as applicable.
Behavioral health assessment requirement
Covered when ALL the following are met for specified combination oral products (MYFEMBREE, ORIAHNN, ORILISSA):
Behavioral health assessment documentation is required; submit records showing history or ongoing treatment and the pre-treatment assessment.
Heavy menstrual bleeding (fibroids) criteria
Covered when ALL the following are met for heavy menstrual bleeding due to fibroids with specific combination products:
Document fibroid-related heavy menstrual bleeding, menopausal status, and contraceptive trial or documented contraindication/intolerance.
The form does not list any blanket exclusions for pituitary suppressive LHRH agents. Coverage is determined by meeting the indication‑specific criteria documented on the prior authorization form (for example, criteria for central precocious puberty, gender dysphoria, endometriosis, preservation of ovarian function, or specified oral combination products) and by any applicable preferred vs non‑preferred drug rules referenced on the form. Providers should refer to the Geisinger preferred drug list at the URL on the form when considering preferred/non‑preferred status.
Requests that do not meet the indication‑specific checklist items on the form may be considered not medically necessary. In addition, lack of required supporting documentation — for example, absence of the required specialist consultation when specified (such as pediatric endocrinologist for CPP or gynecologist for endometriosis), missing diagnostic confirmation (e.g., laparoscopy report for endometriosis), or missing documentation of trial/failure or contraindication for preferred agents — may result in denial of the request.
Diagnosis Codes and Age Thresholds
| DX code ( required ) | Diagnosis code to be submitted on form |
Authorization, Documentation, and Step Therapy Requirements
Prior authorization required — submit completed form and supporting documentation
Prior authorization is required for pituitary suppressive LHRH agents. Providers must submit the completed prior authorization form and all supporting documentation via the PromptPA portal or fax to Geisinger Health Plan.
- Submit completed Pituitary Suppressive Agents, LHRH prior authorization form (form effective 1/3/2022).
- Electronic submission: PromptPA https://ghp.promptpa.com; Fax: 570-271-5610.
Step therapy / prior trials required for non-preferred agents and endometriosis
For non-preferred LHRH agents, the request requires documentation of trial and failure of, or a contraindication or intolerance to, preferred drugs in this class. For endometriosis, approval also requires prior trial and failure of NSAIDs and a failed 3-month trial of oral contraceptives (unless contraindicated/intolerant).
- If non-preferred agent: document trial and failure of preferred class agents or documented contraindication/intolerance and include supporting records.
- Endometriosis-specific: document tried and failed NSAIDs (or contraindication/intolerance) and failed a 3-month trial of oral contraceptives (or contraindication/intolerance).
Required documentation to accompany the PA form
Include the completed prior authorization form with beneficiary and prescriber details, the diagnosis and DX (ICD) code, and supporting clinical documentation addressing the indication-specific checklist items.
- Completed form fields: prescriber name, specialty, NPI, beneficiary name, beneficiary ID, DOB, contact information, prescriber signature and date.
- Diagnosis: submit the diagnosis and DX code (required) on the form.
- Supporting clinical documentation: specialist consultation notes when required (e.g., pediatric endocrinologist for CPP, gynecologist for endometriosis), laparoscopy report for endometriosis, documentation of trials of therapies (NSAIDs, OCs) or reasons for contraindication/intolerance, behavioral health assessment for specified products.
Non-preferred agent requests require documented trial/failure or contraindication/intolerance
Requests for non-preferred LHRH agents must include documentation of trial and failure of, or contraindication or intolerance to, preferred drugs in this class; lack of such documentation may lead to denial.
- Refer to the preferred drug list at https://papdl.com/preferred-drug-list for identification of preferred vs non-preferred agents.
- If 'Yes' to prior trial/failure, submit documentation as indicated on the form; if 'No', the request may be denied.
Step Therapy Requirements
| Requirement | Details / Provider action |
|---|---|
| Step therapy requirement for non-preferred agents | For a non-preferred pituitary suppressive agent (LHRH), the beneficiary must have a history of trial and failure of, or a documented contraindication or intolerance to, the preferred drugs in this class. Providers must refer to the preferred drug list (https://papdl.com/preferred-drug-list) and submit supporting documentation of the trial/failure or contraindication/intolerance. |
| Documentation to submit | Check 'Yes' and submit documentation on the prior authorization form demonstrating the trial and failure or contraindication/intolerance to preferred agents; if 'No' is selected, the requirement is not met. The form directs providers to submit documentation with the request. |
| Where to verify preferred agents | Refer to the Geisinger preferred drug list at https://papdl.com/preferred-drug-list for the current list of preferred and non-preferred drugs in this class when determining required prior trials. |
Key Definitions and Diagnostic Requirements
Quantity and Dose Limits
Site of Care Restrictions
No site-of-care restrictions specified
No site-of-care restrictions are specified on the prior authorization form for these agents.
- Setting noted on form: office (no restrictions specified).
Background and Clinical Context
Luteinizing‑hormone‑releasing hormone (LHRH, also called GnRH) pituitary suppressive agents are medications used to suppress gonadotropin release from the pituitary. The form indicates their typical clinical uses include treatment of central precocious puberty (CPP) — where therapy must be prescribed by or in consultation with a pediatric endocrinologist and meet age/onset thresholds — suppression of puberty for patients with gender dysphoria (when prescribed by or in consultation with providers experienced in transgender medicine and in a manner consistent with current standards of care), management of endometriosis (when prescribed by or in consultation with a gynecologist and with diagnostic confirmation such as laparoscopy), and preservation of ovarian function during gonadotoxic cancer treatment. The form documents the specific clinical checklist items and supporting documentation required for these indications.
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