CurrentAetnaPolicy N/A

Trelstar (triptorelin pamoate) Medication Precertification Request - Coverage Criteria

This document is Aetna's precertification request form and instructions to request authorization for Trelstar (triptorelin pamoate) for initiation or continuation of therapy; it applies to providers submitting precertification for Aetna members.

Policy Summary

PayerAetna

PolicyTrelstar (triptorelin pamoate) Precertification Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed and legible precertification form to Aetna (phone or fax) to request authorization for Trelstar.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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5+indications

2contact methods

Coverage Criteria & Form Items

Form-based coverage criteria

Form lists indications for which Trelstar precertification may be requested; initiation and continuation have separate required items.

Indications for initiation: Breast cancer - ovarian suppression OR Gender dysphoria OR Preservation of ovarian function OR Prostate cancer

Provider must check the relevant indication box for initiation requests

Initiation prior agent question: Has the patient had an ineffective response, contraindication, or intolerance to Eligard? (Yes/No)

Form requests this information for initiation requests

Continuation indications: Prostate cancer

Provider must check the continuation indication box when requesting ongoing therapy

Policy Summary

PayerAetna

PolicyTrelstar (triptorelin pamoate) Precertification Request Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed and legible precertification form to Aetna (phone or fax) to request authorization for Trelstar.

SourceLink

On This Page

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Precertification & Submission Instructions

Prior Authorization

Precertification Required

Prior Authorization Required — Precertification is required for Trelstar (triptorelin pamoate). Submit the completed precertification form to Aetna using the phone or fax numbers below to notify Aetna prior to initiating or continuing therapy.

Aetna Precertification Phone: 1-866-752-7021 (TTY: 711)
Aetna Precertification Fax: 1-888-267-3277
For Medicare Advantage Part B: Use the Medicare Request Form

Note

Prior Alternative Agent Queried

For initiation requests, the form asks whether the patient has had an ineffective response, contraindication, or intolerance to Eligard; this must be completed to support initiation where applicable.

Initiation requests: indicate ineffective response, contraindication, or intolerance to Eligard (Yes/No)

Documentation Required

Required Documentation

Complete all required fields on the precertification form. Providers must supply patient demographics, insurance information, prescriber data (including NPI, state license, DEA as applicable), and full clinical details relevant to the diagnosis and product requested.

Patient demographics and contact information
Prescriber information: credentials, address, phone, fax, State License #, NPI #, DEA #
Product information: medication, dose, frequency
Diagnosis: primary and any secondary ICD codes
Clinical information: select indication(s) and complete initiation or continuation-specific fields

Denial Risk

Incomplete Information May Prevent Evaluation

Provide a complete, legible form and any requested additional information. Incomplete or illegible submissions, or failure to supply requested clarifications, may prevent Aetna from evaluating the request and result in processing delays or denial.

All fields must be completed and legible
Signed acknowledgement (request completed by/signature and date) is required
Failure to provide complete information may result in inability to evaluate the request

Criteria for Initiation Requests

Initial therapy requirements

Initiation requests require the prescriber to indicate the diagnosis and whether there was an ineffective response, contraindication, or intolerance to Eligard.

Initiation documentation: Select one of: Breast cancer - ovarian suppression; Gender dysphoria; Preservation of ovarian function; Prostate cancer

Provider must check the relevant indication box on the form

Prior alternative agent: Indicate whether the patient had an ineffective response, contraindication, or intolerance to Eligard (Yes/No)

Form includes this question for all initiation requests

Product details: Provide product dose and frequency on the form

Dose and frequency fields are required in the product information section

Criteria for Continuation Requests

Continuation therapy requirements

Continuation requests require documentation of benefit and toxicity while on the current regimen.

Continuation documentation: Has the patient experienced clinical benefit to therapy while on the current regimen (e.g., serum testosterone less than 50 ng/dl)? (Yes/No)

Example clinical benefit shown for prostate cancer: serum testosterone < 50 ng/dl

Toxicity assessment: Has the patient experienced an unacceptable toxicity while on the current regimen? (Yes/No)

Both benefit and toxicity questions must be answered for continuation requests

Step	Required prior trial / reason	Documentation requested
1	Ineffective response, contraindication, or intolerance to Eligard	Form asks whether the patient had an ineffective response, contraindication, or intolerance to Eligard for initiation requests; documentation of prior use or clinical rationale may be requested.

Definitions & Key Items

Continuation request clinical benefit

Continuation benefit questionFor continuation requests in prostate cancer the form asks whether the patient has experienced clinical benefit to therapy while on the current regimen (example given: serum testosterone less than 50 ng/dL).

Continuation indication listedProstate cancer is listed as an indication requiring continuation clinical documentation.

Toxicity assessmentForm requires documentation whether the patient has experienced an unacceptable toxicity while on the current regimen (Yes/No).

Response optionsThe form provides explicit Yes/No checkboxes for both clinical benefit and unacceptable toxicity questions for continuation requests.

Required completionThese continuation clinical items must be completed in their entirety for precertification evaluation.

Background

Trelstar (triptorelin pamoate) is a gonadotropin-releasing hormone (GnRH) agonist presented on the form for use in indications including breast cancer — ovarian suppression, gender dysphoria, preservation of ovarian function, and prostate cancer. The form separates initiation versus continuation requests and, for continuation in prostate cancer, specifically asks whether the patient has experienced clinical benefit while on the current regimen (example given: serum testosterone less than 50 ng/dL) and whether the patient has experienced unacceptable toxicity.

Primary ICD Code	Field for primary diagnosis ICD code
Secondary ICD Code	Field for secondary diagnosis ICD code
Other ICD Code	Field for additional diagnosis ICD code

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