Payer PolicyActive
Supprelin® LA (histrelin acetate subcutaneous implant)
EVICORE-MEDICAL_DRUG-CD13CA52
EviCore by Evernorth
Effective: November 1, 2024
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Supprelin LA is covered only for the FDA‑approved pediatric indication—treatment of children with central precocious puberty—and other indications or adult use are excluded. Coverage requires documentation of the diagnosis, is limited to a 12‑month approval, and follows the recommended 50 mg subcutaneous implant in the upper arm replaced every 12 months.
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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