Payer PolicyActive
Triptorelin Extended-Release Suspension (Triptodur)
EVICORE-MEDICAL_DRUG-09981FBB
EviCore by Evernorth
Effective: May 1, 2020
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Triptodur (triptorelin ER) is covered for pediatric central precocious puberty (age ≥2) and as a compendial off‑label use for gender‑dysphoric/gender‑incongruent individuals or those undergoing gender reassignment; other uses are not covered. Approval requires documentation of the diagnosis, off‑label prescribing or consultation by an endocrinologist or a clinician specializing in transgender care, adherence to the recommended dose (22.5 mg IM every 24 weeks), and is issued for 12 months.
Coverage Criteria Preview
Key requirements from the full policy
"Triptodur is indicated for the treatment of pediatric patients 2 years of age and older with central precocious puberty (CPP)."
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