Neighborhood Health Plan RI Triptodur Coverage | OpenPayer

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Neighborhood Health Plan RI Triptodur Coverage | OpenPayer

Initial therapy - Central precocious puberty (CPP)

Covered when ALL of the following are met:

CPP initial criteria: Member has confirmed diagnosis of central precocious puberty (CPP); diagnosis confirmed by a pubertal response to a GnRH agonist stimulation test or a pubertal level on a third-generation LH assay; assessment of bone age versus chronological age supports the diagnosis; member has been evaluated for intracranial tumors with appropriate imaging or laboratory assessment; age at onset of secondary sexual characteristics was less than 8 years for females or less than 9 years for males.see age thresholds

Authorization of 12 months may be granted when criteria met

Initial therapy - Gender dysphoria (pubertal suppression and gender transition)

Covered when ALL of the following are met:

Gender dysphoria initial criteria for pubertal suppression: Member has a diagnosis of gender dysphoria; member has reached Tanner stage 2 of puberty or greater; member is able to make an informed decision to engage in treatment; member's comorbid conditions are reasonably controlled; member has been educated on contraindications and side effects to therapy.Tanner stage >=2

Authorization of 12 months may be granted

Gender dysphoria initial criteria for gender transition: Member has a diagnosis of gender dysphoria; member will receive the requested medication concomitantly with gender-affirming hormones; member is able to make an informed decision to engage in treatment; member's comorbid conditions are reasonably controlled; member has been informed of fertility preservation options; member has been educated on contraindications and side effects to therapy.informed consent and fertility counseling

Authorization of 12 months may be granted

Initial therapy - Preservation of ovarian function

Covered when ALL of the following are met:

Ovarian preservation: Member is premenopausal and undergoing chemotherapy; medication prescribed by or in consultation with a provider experienced in the member's oncology care (and experienced in management of porphyrias if relevant).premenopausal undergoing chemotherapy

Authorization of 3 months may be granted

Initial therapy - Prevention of recurrent menstrual-related attacks in acute porphyria

Covered when ALL of the following are met:

Acute porphyria prevention: Member has a diagnosis of acute porphyria with recurrent menstrual-related attacks and medication is prescribed by or in consultation with a provider experienced in management of porphyrias.clinical diagnosis of recurrent menstrual-related porphyria attacks

Authorization of 12 months may be granted

Continuation therapy - Central precocious puberty (CPP)

Covered when ALL of the following are met:

CPP continuation criteria: Member is currently receiving the requested medication through a paid pharmacy or medical benefit; member meets all initial authorization criteria (including no evidence of treatment failure such as clinical pubertal progression, lack of growth deceleration, or continued excessive bone age advancement); for females, continuation may be granted up to 12 months if the member is currently less than 12 years of age; for males, continuation may be granted up to 12 months if the member is currently less than 13 years of age.age and absence of treatment failure

Continuation requires meeting all initial criteria

Continuation therapy - Gender dysphoria

Covered when ALL of the following are met:

Gender dysphoria continuation criteria: Member has a diagnosis of gender dysphoria; member previously reached Tanner stage 2 of puberty or greater; member is able to make an informed decision to engage in treatment; member's comorbid conditions are reasonably controlled; member has been educated on contraindications and side effects to therapy; fertility preservation was discussed prior to the start of therapy for transition cases; for gender transition, member will receive the requested medication concomitantly with gender-affirming hormones.prior Tanner stage >=2 and counseling

Authorization of 12 months may be granted

All indications for Triptodur (triptorelin) that are not explicitly listed in this policy—i.e., outside the FDA-approved indication for pediatric central precocious puberty and the compendial uses identified—are considered experimental/investigational and not medically necessary.

Use of Triptodur for any indication other than the FDA-approved indication for central precocious puberty and the compendial uses listed in this policy (preservation of ovarian function, gender dysphoria, and prevention of recurrent menstrual-related attacks in acute porphyria) is considered not medically necessary and/or experimental.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization for CPP

Prior authorization may be granted for up to 12 months for treatment of central precocious puberty when diagnostic criteria are met.

Authorization length: up to 12 months
Applies when diagnostic criteria for CPP are documented

Prior Authorization

Prior authorization for gender dysphoria

Prior authorization may be granted for up to 12 months for pubertal suppression or gender transition when diagnostic criteria are met.

Authorization length: up to 12 months
Applies to pubertal hormonal suppression and gender transition when criteria (e.g., diagnosis of gender dysphoria, informed consent, Tanner stage, fertility counseling) are met

Prior Authorization

Prior authorization for ovarian preservation and porphyria

Authorization of 3 months may be granted for preservation of ovarian function in premenopausal members undergoing chemotherapy; 12 months may be granted for prevention of recurrent menstrual-related attacks in acute porphyria and other listed uses as specified.

Ovarian preservation: authorization length = 3 months for premenopausal members undergoing chemotherapy
Acute porphyria / menstrual-related attacks: authorization length = 12 months

Prior Authorization

Continuation requires initial criteria

All members (including new members) requesting continuation must meet all initial authorization criteria.

Continuation requests require documentation that all initial criteria remain satisfied
Applies to continuation of CPP treatment, pubertal suppression, gender transition, and other indications

Documentation Required

Required diagnostic documentation

Submit laboratory report or medical record demonstrating a pubertal response to a GnRH agonist stimulation test or a pubertal level on a third-generation luteinizing hormone (LH) assay. Failure to submit the required diagnostic documentation may result in denial of the authorization request.

Required documentation: lab report or medical record showing pubertal response to GnRH agonist stimulation test OR pubertal level on third-generation LH assay
Missing diagnostic documentation may result in denial

Documentation Required

Prescriber specialty / consultation documentation

For gender dysphoria (pubertal suppression or gender transition), the medication must be prescribed by or in consultation with a provider specialized in the care of transgender youth (e.g., pediatric endocrinologist; family or internal medicine physician; obstetrician-gynecologist) who has collaborated with a mental health provider for members under 18 years of age. For prevention of recurrent menstrual-related attacks in acute porphyria and for ovarian preservation, the medication must be prescribed by or in consultation with a provider experienced in the management of porphyrias or fertility preservation as applicable.

Prescriber requirements: specialty or documented consultation with a provider experienced in transgender youth care for gender dysphoria cases
For members <18 years, evidence of collaboration with a mental health provider is required
For porphyria-related use, prescriber must be experienced in porphyria management

Denial Risk

Missing diagnostic documentation

Failure to submit required diagnostic documentation (laboratory report or medical record showing pubertal response to a GnRH agonist stimulation test or pubertal level on a third-generation LH assay) or required prescriber/consultation documentation may result in denial.

Denial risk if diagnostic tests or specialty/consultation documentation are missing
Ensure all initial criteria are documented for continuation requests