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HealthPartners

Coverage criteria policies

Supprelin LA/Lupron Depot-Peds - Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Supprelin LA requires prior authorization from Pharmacy Administration.

Lupron Depot-Peds requires prior authorization from Pharmacy Administration. Other formulations of Lupron Depot do not require authorization when used in adults for FDA approved indications.

Coverage

Supprelin LA and Lupron Depot-Peds are indicated for precocious puberty and covered for girls under 11 years of age and boys under 12 years of age when a definitive diagnosis exists based on these criteria:

  1. Onset of secondary sexual characteristics earlier than 8 years in females and 9 years in males
  2. Clinical diagnosis should be confirmed by the following:
    1. Confirmation of diagnosis by a pubertal response to a GnRH stimulation test
    2. Bone age advanced one year beyond the chronological age
  3. Documentation of baseline metrics is included for:
    1. Height and weight measurements
    2. Sex steroid levels

Authorizations will be provided until the exclusion age is reached. (girls age = 11 years, boys age = 12 years)

Definitions

Supprelin LA is a gonadotropin releasing hormone (GnRH) agonist indicated for the treatment of children with central precocious puberty (CPP). The recommended dose of Supprelin LA is one 50 mg implant every 12 months.

Lupron Depot-Ped is a gonadotropin releasing hormone (GnRH) agonist indicated in the treatment of children with central precocious puberty. Starting dose recommendations for Lupron Depot-Peds 1-month formulations are based on body weight and as follows:

Body Weight

Recommended Dose

≤ 25 kg

7.5 mg

> 25-37.5 kg

11.25 mg

> 37.5 kg

15 mg

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

ICD-10

Codes

Description

E30.1

Precocious puberty

HCPC

Codes

Description

J9226

Histrelin implant (Supprelin LA), 50 mg

J1950

Injection, leuprolide acetate (for depot suspension), per 3.75 mg

*NOTE This HCPC is not specific for the pediatric formulation.

NDC

Codes

Description

67979000201

Supprelin LA 50 mg kit

00074244003

Lupron Depot-Ped (1-Month) 11.25 mg kit

00074228203

Lupron Depot-Ped (1-Month) 15 mg kit

00074210803

Lupron Depot-Ped (1-Month) 7.5 mg kit

00074377903

Lupron Depot-Ped (3-Month) 11.25 mg kit

00074969403

Lupron Depot-Ped (3-Month) 30 mg (Ped) kit

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

Reference

  1. Supprelin LA prescribing information. Alexion Pharmaceuticals, Inc. 1/2016.
  2. Lupron Depot-Peds prescribing information. AbbVie Inc. 5/2017.

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Policy activity

  • 11/06/2017 - Date of origin
  • 01/01/2018 - Effective date

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