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Central Precocious Puberty

Drug - Lupron Depo-Ped (leuprolide acetate) [AbbVie Inc.]

            Supprelin LA (histrelin acetate implant) [Endo Pharmaceuticals Inc.]

            Triptodur (triptorelin) [Arbor Pharmaceuticals LLC.]

February 2018

Therapeutic area - Central Precocious Puberty

Approval criteria

  • Patient has a clinical diagnosis of central precocious puberty (CPP) identified as:
    • Onset of secondary sexual characteristics earlier than 8 years in females and 9 years in males AND
    • Patient has advanced bone age (bone age at least 1 year greater than chronological age) AND
  • Patient’s clinical diagnosis should be confirmed by ONE of the following GnRH (gonadotropin-releasing hormone) stimulation test results:
    • Peak LH > 5 IU/L after GnRHa (gonadotropin-releasing hormone agonist) OR
    • Ratio of LH (peak): LH(basal) > 3 AND
  • Prescriber attests that CNS (central nervous system) abnormality has been ruled out

Renewal criteria

Continued coverage may be approved annually until female patient reaches 12 years of age and male patient reaches 13 years of age.

Questions?

MHCP Provider Call Center 651-431-2700 or 800-366-5411

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