Payer PolicyActive
Triptorelin Extended-Release Suspension (Triptodur®)
EVICORE-MEDICAL_DRUG-18981A09
EviCore by Evernorth
Effective: January 1, 2022
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Triptodur (triptorelin ER) is covered for pediatric central precocious puberty in patients ≥2 years and for compendial off‑label use in gender‑dysphoric/gender‑incongruent individuals or those undergoing gender reassignment; all other uses are not authorized. Authorization requires diagnosis and age documentation (for CPP), adherence to the 22.5 mg IM every 24 weeks dosing, prescriber or endocrinologist/transgender‑specialist consultation for transgender-related uses, meeting applicable safety criteria, and is granted for up to 12 months.
Coverage Criteria Preview
Key requirements from the full policy
"Treatment of pediatric patients 2 years of age and older with central precocious puberty (CPP)."
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