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
Last review date: December 9, 2016