CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Triptodur (triptorelin) — prior authorization and coverage criteria

Defines prior authorization, coverage criteria, and documentation requirements for Triptodur (triptorelin) for indications including central precocious puberty, gender dysphoria (pubertal suppression and gender transition), preservation of ovarian function during chemotherapy, and prevention of menstrual attacks in acute porphyria for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTriptodur (triptorelin) — prior authorization and coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with diagnostic documentation (e.g., GnRH agonist stimulation test results or third‑generation LH assay) and evidence of required specialist involvement as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthstypical authorization duration for CPP, gender dysphoria, and porphyria prevention

3 monthsauthorization duration for preservation of ovarian function

4 indicationsexplicit covered uses

specialist requiredrequires specialist prescriber for some uses

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Coverage Criteria for Triptodur (triptorelin)

Central precocious puberty (Initial authorization)

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

CPP initial criteria: Diagnosis of central precocious puberty (CPP) confirmed by a pubertal response to a gonadotropin‑releasing hormone (GnRH) agonist stimulation test or a pubertal level on a third‑generation luteinizing hormone (LH) assay; assessment of bone age versus chronological age supports the diagnosis of CPP; intracranial tumor has been evaluated with appropriate laboratory testing and diagnostic imaging when indicated; onset of secondary sexual characteristics occurred before age 8 in females and before age 9 in males.

Central precocious puberty (Continuation authorization)

Authorization of up to 12 months may be granted 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 is not experiencing treatment failure (no clinical pubertal progression, evidence of adequate growth deceleration, and no continued excessive bone age advancement); member is under the continuation age threshold (female <12 years; male <13 years).

Gender dysphoria — pubertal suppression (Initial authorization)

Authorization of 12 months may be granted when ALL of the following are met:

Gender dysphoria pubertal suppression initial: 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; prescriber is a provider specialized in the care of transgender youth and, for members under 18, has collaborated with a mental health provider as appropriate.

Gender dysphoria — gender transition (Initial authorization)

Authorization of 12 months may be granted when ALL of the following are met:

Gender transition initial: 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 prior to therapy initiation; member has been educated on contraindications and side effects to therapy; prescriber specialty and collaboration requirements apply.

Gender dysphoria (Continuation authorization)

Authorization of 12 months may be granted for continued treatment when ALL of the following are met:

Gender dysphoria continuation: Member has a diagnosis of gender dysphoria; for pubertal suppression, member previously reached Tanner stage 2 or greater; member is able to make an informed decision to continue treatment; member's comorbid conditions are reasonably controlled; member has been educated on contraindications and side effects to therapy; for gender transition, documentation exists that the member was informed about fertility preservation options before therapy initiation.

Preservation of ovarian function (Ovarian protection during chemotherapy)

Authorization of 3 months may be granted when ALL of the following are met:

Ovarian preservation: Member is premenopausal and undergoing chemotherapy; clinical rationale for ovarian protection is documented; prescriber is experienced in the relevant oncology/ reproductive‑preservation care and documents the indication and plan.

Prevention of recurrent menstrual-related attacks in acute porphyria

Authorization of 12 months may be granted when ALL of the following are met:

Porphyria prevention: Member has a diagnosis of acute porphyria with recurrent menstrual‑related attacks and documentation supports use of a GnRH agonist to prevent these attacks; authorization duration is typically 12 months.

All indications for Triptodur (triptorelin) that are not explicitly listed in this policy as FDA-approved or accepted compendial uses are considered experimental/investigational and are not covered.

Requests for use of Triptodur for indications other than the FDA‑approved indication and the specified compendial uses (preservation of ovarian function, gender dysphoria, prevention of recurrent menstrual‑related attacks in acute porphyria) are not medically necessary and will not be authorized.

Coding and Age Criteria

Policy reference codesmixed

2504-A	Reference number for Triptodur policy/material
6055-A	Reference number for Triptodur policy/material

Age at onset for CPP criteria — initial authorization

Female age at onsetOnset of secondary sexual characteristics before age 8 years

Male age at onsetOnset of secondary sexual characteristics before age 9 years

Source contextUsed to confirm eligibility for initial CPP treatment

Continuation therapy upper age limits

Female continuation upper age limitMember must be currently less than 12 years of age for continuation approval

Male continuation upper age limitMember must be currently less than 13 years of age for continuation approval

Provider Actions, Authorization Durations, and Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required. Prior authorization is required for the medication. Typical authorization durations: up to 12 months for central precocious puberty (CPP), gender dysphoria (pubertal suppression and gender transition), and prevention of recurrent menstrual-related attacks in acute porphyria; up to 3 months may be typical for ovarian preservation requests (preservation of ovarian function).

Typical approvals: 12 months for CPP, gender dysphoria, porphyria; 3 months may be used for ovarian protection

Documentation Required

Continuation Requires Meeting Initial Criteria

All members (including new members) requesting continuation of therapy must meet all initial authorization criteria. Reauthorization requests should document that the member is not experiencing treatment failure (for CPP: no clinical pubertal progression, appropriate growth deceleration, and controlled bone age advancement) and that the member continues to meet age-related continuation criteria (e.g., females <12 years for CPP continuation, males <13 years for CPP continuation where applicable).

Background

Triptodur (triptorelin) is a gonadotropin‑releasing hormone (GnRH) agonist. It is FDA‑indicated for treatment of central precocious puberty (CPP) in pediatric patients (see policy for age thresholds). In clinical practice and compendial guidance, triptorelin is also used for preservation of ovarian function during chemotherapy, management of gender dysphoria (including pubertal suppression and as part of gender‑affirming transition), and for prevention of recurrent menstrual‑related attacks in acute porphyria. Clinical decisions for CPP require diagnostic confirmation (for example, a pubertal response to a GnRH stimulation test or a pubertal LH level on a third‑generation assay), assessment of bone age, and evaluation for intracranial pathology when indicated.

Definitions and Key Terms

Confirmed central precocious puberty (CPP) — diagnostic definitions

Diagnostic confirmationDiagnosis of CPP confirmed by a pubertal response to a GnRH agonist stimulation test or a pubertal-level result on a third-generation luteinizing hormone (LH) assay

Bone age assessmentAssessment of bone age versus chronological age supports the diagnosis of CPP

Intracranial evaluationIntracranial tumor should be evaluated with appropriate laboratory tests and diagnostic imaging (e.g., CT scan, MRI) when indicated

Pubertal suppression for gender dysphoria — definition and requirements

Tanner stage requirementMember has reached Tanner stage 2 of puberty or greater for pubertal suppression

Informed decision and counselingMember is able to make an informed decision and has been educated on contraindications and side effects; fertility preservation counseling documented for transition-related care