CurrentMass General Brigham Health PlanPolicy N/A

Triptodur (triptorelin) prior authorization for central precocious puberty

This policy governs prior authorization and coverage criteria for Triptodur (triptorelin) for treatment of central precocious puberty (CPP) in Mass General Brigham Health Plan members, including age limits and prescriber requirements.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTriptodur (triptorelin) prior authorization for central precocious puberty

Policy CodePolicy N/A

Change TypeRevised criteria and requirements (see updates)

Effective DateDec 1, 2019

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of CPP diagnosis, age criteria, and pediatric endocrinologist prescriber or consultation.

SourceLink

POLICY UPDATE CHANGES

Removed testing requirements, added started & stabilized requirement, and combined male and female criteria.

>=2minimum patient age for treatment

<=12max approval age - females

<=13max approval age - males

Onset <8F/<9MCPP onset threshold

Coverage Criteria for Triptodur (triptorelin)

Initial or Continuation Authorization

Authorization may be granted when ONE of the following is met

Authorization pathways

Pathway A: Member is currently receiving treatment with Triptodur (excludes when the product is obtained as samples or via manufacturer's patient assistance programs).
Document current treatment status and that product was not obtained as samples or via patient assistance program.
Pathway B
- Diagnosis of central precocious puberty (CPP) with onset of secondary sex characteristics before age 8 for females or before age 9 for males.
- Member is at least 2 years of age.

Policy Summary

PayerMass General Brigham Health Plan

PolicyTriptodur (triptorelin) prior authorization for central precocious puberty

Policy CodePolicy N/A

Change TypeRevised criteria and requirements (see updates)

Effective DateDec 1, 2019

Next Review DateN/A

Key ActionSubmit prior authorization with documentation of CPP diagnosis, age criteria, and pediatric endocrinologist prescriber or consultation.

SourceLink

On This Page

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Age and Diagnostic Thresholds

inv-04: Minimum age

Minimum patient ageAt least 2 years of age

Source indication ageTriptodur is FDA indicated for treatment of CPP in patients 2 years and older

Authorization requirementMember must be ≥2 years to meet criteria for authorization

inv-05: CPP onset thresholds

Female CPP onset thresholdOnset of secondary sex characteristics before age 8

Male CPP onset thresholdOnset of secondary sex characteristics before age 9

Documentation neededClinical documentation must show age at onset of secondary sex characteristics to establish CPP

inv-06: Maximum approval ages

Maximum approval age - femalesApprovals granted up to age 12 for females

Maximum approval age - malesApprovals granted up to age 13 for males

Requests beyond limitsRequests for approval beyond these ages are not supported by the policy

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for Triptodur (triptorelin). This requirement applies to both continuation requests and new starts; authorization will not be granted when product is obtained as samples or through manufacturer's patient assistance programs.

Applies to Pharmacy and Medical benefits as specified by plan.
Contact: All Plans Phone: 877-519-1908, Fax: 855-540-3693; Non-Specialty Phone: 800-711-4555, Fax: 844-403-1029

Step Therapy

Step Therapy Note

Program indicates 'Step Therapy' but no explicit step sequence is provided in source policy. Providers should not assume a multi-step requirement beyond the listed criteria (e.g., prior trial of Lupron) and should submit required documentation for review.

Documentation Required

Required Documentation

Documentation must demonstrate: diagnosis of central precocious puberty (CPP) with onset of secondary sex characteristics before age 8 (females) or before age 9 (males); member is at least 2 years old; evidence the prescriber is a pediatric endocrinologist or that a consultation with a pediatric endocrinologist occurred; and for continuation requests, documentation that the member is currently receiving Triptodur (excluding samples or manufacturer assistance).

Denial Risk

Triggers for Denial

Authorization may be denied if any of the following apply: the diagnosis is not CPP; the member is not currently receiving Triptodur for continuation requests; required documentation (age, diagnosis onset criteria, pediatric endocrinologist involvement, or prior trial/contraindication to Lupron when applicable) is missing or insufficient; or the member falls outside age limitations (females >12 years, males >13 years).

Denial triggers include: diagnosis not CPP; member not currently receiving Triptodur for continuation requests; lack of documentation of required age/onset criteria; no pediatric endocrinologist involvement or consultation; no documentation of inadequate response/contraindication to Lupron when that criterion is used.
Age limitations: females >12 years and males >13 years are not eligible for approval per policy.

OpenPayer

Triptodur (triptorelin) prior authorization for central precocious puberty

Coverage Criteria for Triptodur (triptorelin)

Age and Diagnostic Thresholds

Provider Requirements and Prior Authorization

Background and Drug Information

Definitions