Drugs and Biologicals, Coverage of, for Label and Off-Label Uses
J6 · Effective Oct 1, 2015
6 active Medicare policies list J9217, and 35 commercial payer policies list it. See each policy's status for the code and its official source. Listing a code is not a coverage decision: read each policy’s source for the requirements that apply.
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J6 · Effective Oct 1, 2015
JK · Effective Oct 1, 2015
JJ · Effective Feb 19, 2023
JM · Effective Feb 19, 2023
J6 · Effective Apr 1, 2026
National · Effective Oct 1, 2025
35 policies from 16 payers
Summary of the payer’s published policy. Not a coverage determination — confirm with the payer before submitting.
Codes labeled “Inferred from policy title” are not listed in the policy document; Backwork attached them because the policy title names the drug.
| Policy | Effective | Status of J9217 |
|---|---|---|
| Leuprolide Acetate (Fensolvi, Lupron Depot- PED, Lupron Depot)Effective 01/01/2022 - 11/30/2022 | Jan 1, 2022 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Leuprolide Acetate (Fensolvi, Lupron Depot- PED, Lupron Depot)Effective 02/01/2021 - 12/31/2021 | Feb 1, 2021 | Prior auth requiredInferred from policy title |
| Leuprolide Acetate (Fensolvi, Lupron Depot- PED, Lupron Depot)Effective 12/01/2022 - 10/31/2023 | Dec 1, 2022 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Leuprolide acetate (Fensolvi, Lupron Depot-PED, Lupron Depot) Non-oncology | Nov 1, 2025 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Leuprolide acetate (Fensolvi, Lupron Depot-PED, Lupron Depot) Non-oncologyEffective 03/01/2025 - 10/31/2025 | Nov 1, 2024 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Leuprolide acetate (Fensolvi, Lupron Depot-PED, Lupron Depot)_Non-oncEffective 11/01/2023 - 10/31/2024 | Nov 1, 2023 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Leuprolide acetate (Fensolvi, Lupron Depot-PED, Lupron Depot)_Non-oncEffective 11/01/2024 - 02/28/2025 | Nov 1, 2024 | Prior auth requiredInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
|---|
| Policy | Effective | Status of J9217 |
|---|---|---|
| Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments | Feb 20, 2024 | Covered |
| Benign Prostatic Hyperplasia | Feb 8, 2024 | Covered |
| Gonadotropin-Releasing Hormone Analogs and Antagonists | Jul 14, 2023 | Covered |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Leuprolide Acetate (Eligard, Vabrinty) | May 1, 2004 | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Leuprolide Acetate Depot Suspension - [Lupron Depot (1 month) 7.5mg, Lupron Depot (3 month) 22.5mg, Lupron Depot (4-Month) 30 mg, Lupron Depot (6-Month) 45 mg]; Leuprolide Acetate Depot (3-month 22.5 mg): Lutrate Depot (3-month 22.5 mg) | May 1, 2004 | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Leuprolide Suspension (Lupron Depot, Leuprolide Acetate Depot)1-Month 3.75mg, 3-Month 11.25 mg) | May 1, 2004 | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Leuprolide (Camcevi, Camcevi ETM, Eligard, Fensolvi, Lupron Depot) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Leuprolide (Camcevi, Camcevi ETM, Eligard, Fensolvi, Lupron Depot) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists | Aug 15, 2025 | Covered |
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists | Aug 15, 2025 | Covered |
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists | Aug 15, 2025 | Covered |
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Gonadotropin-Releasing Hormone (GnRH) Agonists and Antagonists | Aug 15, 2025 | Covered |
| Oncology Medications | Jul 1, 2026 | Covered |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Leuprolide (Camcevi, Camcevi ETM, Eligard, Fensolvi, Lupron Depot) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Leuprolide (Camcevi, Camcevi ETM, Eligard, Fensolvi, Lupron Depot) | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Gonadotropin Releasing Hormone Analogs | Jul 1, 2025 | Covered |
| Oncology Medication Clinical Coverage | Sep 1, 2026 | Covered |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Gonadotropin Releasing Hormone Analogs | Jul 1, 2025 | Covered |
| Oncology Medication Clinical Coverage | Sep 1, 2026 | Covered |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Gonadotropin Releasing Hormone Analogs | Jul 1, 2025 | Covered |
| Oncology Medication Clinical Coverage | Sep 1, 2026 | Covered |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Leuprolide Acetate (e.g., Lupron Depot; Fensolvi) for Non-Oncologic Indications | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Cigna MedOnc Master Drug List.pdf | Not recorded | Prior auth required |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Leuprolide Acetate (Eligard, Fensolvi, Lupron Depot, Lupron Depot-Ped), Leuprolide mesylate (Camcevi); CP.PCH.53. | Not recorded | Covered with conditionsInferred from policy title. Not listed in the policy document; attached because the policy title names the drug. |
| Policy | Effective | Status of J9217 |
|---|---|---|
| Q4 - 2026 JHP MedOnc Master Drug List.pdf | Not recorded | Prior auth required |