CurrentCommunity-CarePolicy N/A

Triptodur (triptorelin) Medical Benefit Medication Utilization Policy

Defines medical benefit coverage criteria, quantity limits, authorization period, and applicable HCPCS code for triptorelin (Triptodur) when used to treat central precocious puberty in pediatric patients.

Policy Summary

PayerCommunity-Care

PolicyTriptodur (triptorelin) Medical Benefit Medication Utilization Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionPrescriptions must be written by an endocrinologist and documentation of luteinizing hormone and sex steroid level results must be submitted for authorization.

SourceLink

POLICY UPDATE CHANGES

No material changes

1Covered Indication

1Applicable HCPCS code

22.5 mg/24wQuantity Limit

1 yrAuthorization Period

Coverage Summary

Coverage stance: Covered with criteria. Scope: Defines medical benefit coverage criteria, quantity limits, authorization period, and applicable HCPCS code for Triptodur (triptorelin) when used to treat central precocious puberty in pediatric patients.

Medical Necessity — Initial Therapy

Medical Necessity - Central Precocious Puberty

Covered when ALL of the following are met:

ALL of the following

Prescriber: Prescribed by an endocrinologist
Diagnostic confirmation: Diagnosis of central precocious puberty confirmed by luteinizing hormone and sex steroid levels
Age < 13 years< 13 years
Clinical finding: Early onset of secondary sexual characteristics
defined as < 8 years in girls or < 9 years in boys
Bone age advanced > 2 standard deviations beyond chronological age> 2 standard deviations
Contraindication: Does not have a tumor (intracranial, steroid secreting, or chorionic gonadotropin secreting) requiring surgery, radiation therapy, or chemotherapy

Provider Actions & Authorization Requirements

Prior Authorization

Prescriber specialty requirement

Prescriptions must be written by an endocrinologist for coverage under this policy.

Documentation Required

Diagnostic confirmation

Documentation of central precocious puberty confirmation with luteinizing hormone and sex steroid level results must be submitted for authorization.

Billing Rule

Quantity limit per injection

If approved, authorized quantity is up to one 22.5 mg injection every 24 weeks.

Affected code: J3316

Prior Authorization

Authorization period

If approved, coverage is authorized for one year (subject to benefit changes); reauthorization required thereafter.

Background

Triptodur (triptorelin) is an extended-release gonadotropin-releasing hormone agonist indicated for the treatment of central precocious puberty. Coverage requires a prescription from an endocrinologist and documentation confirming the diagnosis with luteinizing hormone and sex steroid level results prior to authorization.

Central precocious puberty: Early activation of the hypothalamic-pituitary-gonadal axis leading to early secondary sexual characteristics; confirmed by LH and sex steroid levels.