Payer PolicyActive
Triptorelin Extended-Release Suspension (Triptodur)
EVICORE-MEDICAL_DRUG-ED316D96
EviCore by Evernorth
Effective: April 1, 2021
Updated: January 13, 2026
created · Dec 4, 2025
Policy Summary
Triptodur (triptorelin ER) is covered only 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; other uses are not covered. Approval requires documented diagnosis and meeting applicable safety criteria, specialist prescription or consultation for transgender‑related use (endocrinologist or clinician specializing in transgender care), and is authorized for up to 12 months with the recommended dose 22.5 mg IM every 24 weeks.
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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