Histrelin SC implant (Supprelin LA®)

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

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