SUPPRELIN LA (histrelin SC implant)

SUPPRELIN LA (histrelin SC implant)

OFFICE ADMINISTRATION 

Indications for Prior Authorization:

• Central precocious puberty

Patients must meet the following criteria for the indication(s) above:

• Patients two years and older. Discontinue at age 11 years for girls and 12 years for boys

All of the following must be met as a condition(s) for coverage:

• Age between two and 12 years
• Trial/failure/adverse effects of leuprolide depot
  • 0.3mg/kg/dose IM q month (Lupron Depot PED [one month]) OR
  • 11.25mg to 30mg IM q 3 months (Lupron Depot PED [3 month])

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

• Idiopathic short stature
• Ovarian cancer
• Prophylaxis for chemo therapy induced gonadal injury
• Considered experimental and investigational for all other indications outside of the FDA indication because there is insufficient evidence in peer reviewed literature

Dose:

• One implant (50mg) q 12 months

Approval:

One year