CurrentMass General Brigham Health PlanPolicy N/A

Supprelin LA (histrelin) prior authorization

Defines prior authorization requirements for Supprelin LA (a GnRH agonist) under the pharmacy benefit for Mass General Brigham Health Plan Commercial/Exchange members; covers indications, continuation, limitations, and specialty fill requirements.

Policy Summary

PayerMass General Brigham Health Plan

PolicySupprelin LA (histrelin) prior authorization

Policy CodePolicy N/A

Change TypeBenefit applicability revised

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization through the pharmacy benefit and ensure fill at a contracted specialty pharmacy.

SourceLink

POLICY UPDATE CHANGES

Updated policy to reflect that it no longer applies to the medical benefit.

Commercial/ExchangePlan applicability

PharmacyBenefit type

Prior AuthProgram type

Specialty pharmacySpecialty fill

Initial: 12m/3mApproval durations

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Coverage Criteria

Initial Therapy - CPP (female)

Authorization may be granted for treatment of CPP in a female member when ALL of the following are met:

CPP female initial: Intracranial tumor has been evaluated by appropriate lab tests and diagnostic imaging (e.g., computed tomography [CT] scan, magnetic resonance imaging [MRI]).required

From policy A.1.a

CPP female initial: The diagnosis of CPP has been confirmed by a pubertal response to a gonadotropin releasing hormone (GnRH) agonist test or a pubertal level of a third-generation luteinizing hormone (LH) assay.required

From policy A.1.b

CPP female initial: The assessment of bone age versus chronological age supports the diagnosis of CPP.required

From policy A.1.c

CPP female initial: The member was less than 8 years of age at the onset of secondary sexual characteristics.required

From policy A.1.d

Initial Therapy - CPP (male)

Authorization may be granted for treatment of CPP in a male member when ALL of the following are met:

CPP male initial: Intracranial tumor has been evaluated by appropriate lab tests and diagnostic imaging (e.g., CT scan, MRI).required

From policy A.2.a

CPP male initial: The diagnosis of CPP has been confirmed by a pubertal response to a GnRH agonist test or a pubertal level of a third-generation LH assay.required

From policy A.2.b

CPP male initial: The assessment of bone age versus chronological age supports the diagnosis of CPP.required

Initial Therapy - Gender dysphoria (pubertal suppression)

Authorization may be granted for pubertal hormonal suppression in an adolescent member when ALL of the following are met:

Gender dysphoria pubertal suppression initial: The member has a diagnosis of gender dysphoria.required

From policy B.1.a

Gender dysphoria pubertal suppression initial: The member has reached Tanner stage 2 of puberty or greater.required

From policy B.1.b

Gender dysphoria pubertal suppression initial: The member's comorbid conditions are reasonably controlled.required

From policy B.1.c

Initial Therapy - Gender dysphoria (gender transition)

Authorization may be granted for gender transition when ALL of the following are met:

Gender transition initial: The member has a diagnosis of gender dysphoria.required

From policy B.2.a

Gender transition initial: The member will receive Supprelin LA concomitantly with gender-affirming hormones.required

From policy B.2.b

Gender transition initial: The member's comorbid conditions are reasonably controlled.required

From policy B.2.c

Initial Therapy - Ovarian preservation

Authorization may be granted for preservation of ovarian function when ALL of the following are met:

Ovarian preservation initial: Member is premenopausal and undergoing chemotherapy.1 required

Initial approvals granted for 3 months per Limitations

Initial Therapy - Acute porphyria

Authorization may be granted when ALL of the following are met:

Porphyria prevention initial: Requested medication is prescribed by or in consultation with a physician experienced in the management of porphyrias.1 required

From policy D.1

Continuation Therapy - CPP (female)

Authorization may be granted for continuation of therapy for CPP in a female member when ALL of the following are met:

CPP female continuation: The member is currently less than 12 years of age.both required

From policy N.9.A.1.a

CPP female continuation: The member is currently receiving the requested medication through a paid pharmacy or medical benefit and is not experiencing treatment failure (e.g., clinical pubertal progression, lack of growth deceleration, continued excessive bone age advancement).both required

From policy N.9.A.1.b

Continuation Therapy - CPP (male)

Authorization may be granted for continuation of therapy for CPP in a male member when ALL of the following are met:

CPP male continuation: The member is currently less than 13 years of age.both required

From policy N.9.A.2.a

CPP male continuation: The member is currently receiving the requested medication through a paid pharmacy or medical benefit and is not experiencing treatment failure (e.g., clinical pubertal progression, lack of growth deceleration, continued excessive bone age advancement).both required

From policy N.9.A.2.b

Continuation Therapy - Gender dysphoria

Authorization may be granted for continued treatment for pubertal hormonal suppression or gender transition when ALL of the following are met:

Gender dysphoria continuation pubertal suppression: The member has a diagnosis of gender dysphoria.all required

From policy N.10.1.a

Gender dysphoria continuation pubertal suppression: The member has previously reached Tanner stage 2 of puberty or greater.all required

From policy N.10.1.b

Gender dysphoria continuation pubertal suppression: The member's comorbid conditions are reasonably controlled.all required

Continuation Therapy - Other indications

Authorization for continuation when ALL initial criteria met:

Other indications continuation: All members requesting continuation (including new members) must meet all initial authorization criteria.required

From policy N.11

The policy recognizes specific compendial uses for Supprelin LA in addition to the FDA-approved indication. These listed compendial uses are: (1) gender dysphoria (also referred to as gender non-conforming or transgender persons), (2) preservation of ovarian function, and (3) prevention of recurrent menstrual-related attacks in acute porphyria.

Any indication for Supprelin LA that is not the FDA-approved use for central precocious puberty or one of the three listed compendial uses above is considered experimental/investigational and not medically necessary.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required under the pharmacy benefit. This medication is designated specialty and must be filled at a contracted specialty pharmacy.

Program type: Prior Authorization (pharmacy benefit)
Specialty pharmacy fill required — use contracted specialty pharmacy
Contact (Pharmacy Benefit): Phone 800-711-4555; Fax 844-403-1029
Contact (Medical Benefit): Phone 833-895-2611; Fax 888-656-6671

Step Therapy

No step therapy requirement is listed for this medication in the policy.

Definitions

Supprelin LA — definition

DrugSupprelin LA (histrelin) — a GnRH agonist

Indication (FDA)Treatment of children with central precocious puberty (CPP)

Policy applicabilityPrior authorization required under the pharmacy benefit; specialty pharmacy fill

Central precocious puberty (CPP) — diagnostic confirmation

Diagnostic confirmation method 1Pubertal response to a GnRH agonist stimulation test

Diagnostic confirmation method 2Pubertal level on a third‑generation luteinizing hormone (LH) assay

Supportive findings

Background

Supprelin LA (histrelin) is a gonadotropin-releasing hormone (GnRH) agonist indicated for the treatment of children with central precocious puberty (CPP). The policy also addresses recognized compendial uses including pubertal suppression for gender dysphoria, preservation of ovarian function (for patients undergoing chemotherapy), and prevention of recurrent menstrual-related attacks in acute porphyria.

Revision History

2026-10-08policy revisionLatest

Policy updated to reflect that it no longer applies to the medical benefit (moved applicability to pharmacy benefit only); effective date listed as 2026-01-01.

2023-12-13formulary update

Reviewed at December P&T and switched from SGM to Custom; effective 2024-01-01.

Policy Summary

PayerMass General Brigham Health Plan

PolicySupprelin LA (histrelin) prior authorization

Policy CodePolicy N/A

Change TypeBenefit applicability revised

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization through the pharmacy benefit and ensure fill at a contracted specialty pharmacy.

SourceLink

On This Page

CPP male initial: The member was less than 9 years of age at the onset of secondary sexual characteristics.required

From policy A.2.d

Gender dysphoria pubertal suppression initial: The member has been educated on any contraindications and side effects to therapy.required

From policy B.1.d

Gender dysphoria pubertal suppression initial: The member has been informed of fertility preservation options.required

From policy B.1.e

Gender dysphoria pubertal suppression initial: The medication is prescribed by or in consultation with a provider specialized in the care of transgender youth who has collaborated care with a mental health provider for patients less than 18 years of age (e.g., pediatric endocrinologist, family or internal medicine physician, obstetrician-gynecologist).required

From policy B.1.f

Gender transition initial: The member has been educated on any contraindications and side effects to therapy.required

From policy B.2.d

Gender transition initial: The member has been informed of fertility preservation options.required

From policy B.2.e

Gender transition initial: The medication is prescribed by or in consultation with a provider specialized in the care of transgender youth who has collaborated care with a mental health provider for patients less than 18 years of age (e.g., pediatric endocrinologist, family or internal medicine physician, obstetrician-gynecologist).required

From policy B.2.f

From policy N.10.1.c

Gender dysphoria continuation pubertal suppression: The member has been educated on any contraindications and side effects to therapy.all required

From policy N.10.1.d

Gender dysphoria continuation pubertal suppression: Before the start of therapy, the member has been informed of fertility preservation options.all required

From policy N.10.1.e

Gender dysphoria continuation transition: The member has a diagnosis of gender dysphoria.all required

From policy N.10.2.a

Gender dysphoria continuation transition: Supprelin LA will be given concomitantly with gender-affirming hormones.all required

From policy N.10.2.b

Gender dysphoria continuation transition: The member's comorbid conditions are reasonably controlled.all required

From policy N.10.2.c

Gender dysphoria continuation transition: The member has been educated on any contraindications and side effects to therapy.all required

From policy N.10.2.d

Gender dysphoria continuation transition: Before the start of therapy, the member has been informed of fertility preservation options.all required

From policy N.10.2.e

Documentation Required

Required Documentation

Documentation must support the diagnosis and appropriateness of therapy. Include objective diagnostic confirmation and relevant evaluations per indication.

For central precocious puberty (CPP): documentation of evaluation for intracranial tumor (lab tests and CT or MRI), confirmation of CPP by pubertal response to a GnRH agonist stimulation test or pubertal-level third-generation LH assay, bone age assessment relative to chronological age, and age at onset of secondary sexual characteristics (<8 years for females; <9 years for males).
For gender dysphoria (pubertal suppression or gender transition): diagnosis of gender dysphoria, Tanner stage (≥2 for pubertal suppression), documentation that comorbid conditions are reasonably controlled, counseling on contraindications/side effects and fertility preservation options, and that prescriber is or consulted with a provider specialized in transgender youth care and has collaborated with a mental health provider for patients <18 years.
For preservation of ovarian function: documentation that member is premenopausal and undergoing chemotherapy.
For prevention of recurrent menstrual-related attacks in acute porphyria: documentation that medication is prescribed by or in consultation with a physician experienced in porphyria management.
Include prior treatment history to confirm treatment-naïve status when applicable or evidence of current treatment if member is new to plan within past 90 days.

Denial Risk

Denial Triggers

Requests may be denied if clinical criteria or documentation requirements are not met, or if member is not treatment-naïve and no exception applies.

Denial triggers include: lack of required diagnostic confirmation (e.g., GnRH stimulation test or third-generation LH assay for CPP), missing imaging/lab evaluation for suspected intracranial pathology, bone age assessment not supporting CPP, age at onset outside policy thresholds, inadequate documentation for gender dysphoria criteria (Tanner stage, specialist involvement, mental health collaboration for <18), missing chemotherapy documentation for ovarian preservation, or absence of specialist consultation for porphyria.
Requests from members new to the plan may be denied if the member is not treatment-naïve within 90 days and is not currently receiving the medication (exceptions apply if member is actively receiving therapy).
Initial approval limits: 3 months for ovarian preservation; 12 months for all other indications.

Bone age assessment showing advancement vs chronological age supports CPP diagnosis

Age‑of‑onset criteriaFemale: onset of secondary sexual characteristics < 8 years; Male: onset < 9 years