Payer PolicyActive
Supprelin® LA (histrelin acetate subcutaneous implant)
EVICORE-MEDICAL_DRUG-698354E0
EviCore by Evernorth
Effective: November 1, 2025
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Supprelin LA (histrelin acetate 50 mg subcutaneous implant) is covered only for the FDA‑approved use: treatment of children with central precocious puberty and is not covered for other indications. Coverage is limited to one 50 mg implant placed subcutaneously in the upper arm every 12 months with 12‑month approval, and documentation of the central precocious puberty diagnosis is required.
Coverage Criteria Preview
Key requirements from the full policy
"Supprelin LA (histrelin acetate subcutaneous implant) is indicated for the treatment of children with central precocious puberty."
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