Payer PolicyActive
Triptodur® (triptorelin extended-release suspension)
EVICORE-MEDICAL_DRUG-0E7BDF8B
EviCore by Evernorth
Effective: November 1, 2025
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Triptodur (triptorelin ER) is covered only for pediatric patients ≥2 years with central precocious puberty and for compendial off‑label use in gender‑dysphoric/gender‑incongruent individuals or those undergoing gender reassignment; other indications are not covered. Approval requires prescription by or consultation with an endocrinologist or a transgender‑care specialist, documentation of diagnosis and age (for CPP), a treatment plan with intent to give 22.5 mg IM every 24 weeks, and is authorized for up to 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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