Payer PolicyActive
Triptorelin Extended-Release Suspension (Triptodur)
EVICORE-MEDICAL_DRUG-098B5BF8
EviCore by Evernorth
Effective: April 1, 2019
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Triptodur (triptorelin extended‑release) is covered only for the FDA‑approved indication of central precocious puberty, with approval limited to 12 months and recommended dosing of 22.5 mg IM every 24 weeks; non‑FDA indications are not covered. Approval requires documentation of the CPP diagnosis, and continuation beyond the initial 12 months depends on documented clinical factors (age, bone age, target height, growth velocity, and social desire regarding pubertal progression).
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of central precocious puberty (FDA-approved indication)."
Sign up to see full coverage criteria, indications, and limitations.